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DISEASES OF THE SKIN 



VAN HARLINGEN 



TEXT-BOOK 



OF 



DISEASES OF THE SKIN 



BY 

ARTHUR VAN HARLINGEN, Ph.B. (Yale) M. D. 

Emeritus Professor of Dermatology in the Philadelphia Polyclinic. 
Dermatologist to the Children's Hospital. Fellow of the Col- 
lege of Physicians of Philadelphia. Member of the 
American Dermatological Association. 



FOURTH EDITION 

THOROUGHLY REVISED AND REARRANGED 

WITH 102 ILLUSTRATIONS. 



PHILADELPHIA 

BLAKISTON'S SON & CO, 

1012 WALNUT STREET 

1907 



« 









UffRARY of CONGRESS 
Two Cooler Received 

SEP 28 190? 

^ Copynrht Entry 

Set> 3 \<\*1 

CLASS A XXc, No/ 

tattoo 

COPY B. 



Copyright, 1907, 
By P. BLAKISTON'S SON & CO. 



Printed by 

The Maple Press 

York. Pa. 



PREFACE TO THE FOURTH EDITION 



The present differs from previous editions of this work in 
the arrangement of the description of the various diseases. These, 
instead of being entered alphabetically, as before, are now- 
arranged according to the classification generally adopted by 
American teachers. It is hoped that this will make the book 
more useful to the student. 

The text has been almost entirely rewritten to bring it up to 
the present state of our knowledge; a large number of diseases 
are described which have not previously been included and a 
brief account of the pathologic anatomy of the various affections 
has been inserted. 

A considerable number of new illustrations have been added. 
Some of these are from drawings by the author, others are from 
photographs of cases occurring under his own observation and 
that of friends. 

His best thanks are due to Prof. Louis A. Duhring and Prof. 
Henry W. Stelwagon for advice and assistance in the preparation 
of the present edition. To Dr. Duhring for the use of several 
photographs of disease and also of certain drawings of the 
anatomy of the hair and of parasites made by the author for 
Duhring's "Treatise on Diseases of the Skin" some years since 
and published in that work. 

Dr. Stelwagon has kindly allowed the author to make use of 
his "Treatise on Diseases of the Skin" and this has been freely 
drawn upon in the description of some of the rarer diseases 



VI PREFACE. 

and in the sections on pathologic anatomy. The same friend 
has lent several photographs for use in this edition. 

The scope of this work has not permitted extensive reference 
to original articles but this has been done to a much greater 
extent than in previous editions. The author may also here 
express his indebtedness to the text-book of Hyde and Mont- 
gomery, and Duhring's "Cutaneous Medicine" and, particu- 
larly in the anatomical sections, to the admirable "Handbook 
of the Pathology of the Skin" by Macleod, of London. 



CONTENTS. 



PAGE 

Anatomy and Physiology of the Skin i 

Symptomatology 22 

Classification 30 

CLASS I. HYPEREMIAS. 

Erythema 37 

Erythema Hyperaemicum 37 

Erythema Intertrigo 38 

Erythema Scarlatinoides 40 

CLASS II. INFLAMMATIONS. 

Erythema Multiforme 43 

Erythema Nodosum 47 

Erythema Induratum 48 

Pellagra 50 

Urticaria 51 

Urticaria Pigmentosa 56 

(Edema Angioneuroticum 57 

Pityriasis Rosea 59 

Dermatitis Exfoliativa 61 

Dermatitis Exfoliativa Epidemica 63 

Dermatitis Exfoliativa Neonatorum 63 

Prurigo 64 

Lichen Ruber 65 

Lichen Scrofulosus 69 

Psoriasis 71 

Eczema 83 

Eczema Seborrhceicum 141 

Herpes 144 

Herpes Simplex 144 

Herpes Zoster 150 

Hydroa Vacciniforme 159 

vii 



Vlll CONTENTS. 

PAGE 

Pompholyx 159 

Dermatitis Herpetiformis 160 

Pemphigus 165 

Epidermolysis Bullosa 168 

Dermatitis Repens 169 

Impetigo Simplex 169 

Impetigo Contagiosa 171 

Ecthyma 174 

Impetigo Herpetiformis 177 

Furunculus 177 

Carbunculus 181 

Plegmona Diffusa 183 

Dissection Wounds 184 

Equinia 184 

Pustula Maligna 185 

Erysipelas 186 

Erysipeloid 188 

Dermatitis Gangrenosa Infantum 189 

Multiple Gangrene of the Skin in Adults 189 

Diabetic Gangrene 191 

Symmetric Gangrene 191 

Dermatitis Calorica 192 

Dermatitis Congelationis 192 

Dermatitis Venenata 195 

X-ray Dermatitis 200 

Dermatitis Factitia 202 

Dermatitis Medicamentosa 205 

Varicella 209 

Vaccinal Eruptions 211 

CLASS III. HEMORRHAGES. 

Purpura 213 

Purpura. Scorbutica 217 

CLASS IV. HYPERTROPHIES. 

Lentigo 218 

Chloasma 218 

Argyria ' 220 



CONTENTS. IX 

PAGE 

Tattoo Marks 220 

Naevus Pigmentosus 221 

Acanthosis Nigricans 224 

Clavus 225 

Callositas 226 

Keratosis Palmaris et Plantaris 227 

Keratosis Senilis 228 

Keratosis Pilaris 229 

Keratosis Follicularis 230 

Verruca 231 

Cornu Cutaneum 235 

Ichthyosis 238 

Porokeratosis 244 

Angiokeratoma 244 

Scleroderma 245 

Sclerema Neonatorum 249 

(Edema Neonatorum 251 

Elephantiasis 251 

Dermatolysis '. . 257 

CLASS V. ATROPHIES. 

Atrophia Cutis 259 

Atrophia Maculata et Striata 260 

Hemiatrophia Facialis 260 

Vitiligo 262 

Albinismus 263 

Ainhum 263 

Perforating Ulcer of the Foot 264 

CLASS VI. NEW GROWTHS. 

Cicatrix 265 

Keloid 265 

Dermatitis Papillaris Capillitii 268 

Molluscum Contagiosum 270 

Multiple Benign Cystic Epithelioma 272 

Adenoma Sebaceum 272 

Lymphangioma 273 

Xanthoma 275 

Xanthoma Diabeticorum 276 



X CONTENTS. 

PAGE 

Colloid Degeneration of the Skin 277 

Naevus Vasculosus 277 

Telangiectasis 280 

Angioma Serpiginosum 280 

Fibroma 281 

Neuroma 285 

Myoma 286 

Rhinoscleroma 286 

Tuberculosis Cutis 287 

Accidental Inoculations 287 

Tuberculosis Verrucosa .......: j . . 288 

Tuberculous Ulcers . .... 289 

Scrofuloderma . 289 

Lupus Vulgaris 292 

Lupus Erythematosus 302 

Syphilis 307 

The Erythematous Syphiloderm .... 308 

The Pigmentary Syphiloderm 308 

The Papular Syphiloderm 309 

The Vesicular Syphiloderm 310 

The Pustular Syphiloderm 311 

The Tubercular Syphiloderm 313 

The Gummatous Syphiloderm 313 

The Bullous Syphiloderm 314 

Skin Diseases in Hereditary Syphilis 315 

Delhi Boil 319 

Frambcesia 319 

Verruga Peruana 320 

Carcinoma Cutis 321 

Epithelioma 321 

Paget's Disease 329 

Xeroderma Pigmentosum 330 

Sarcoma Cutis 331 

Granuloma Fungoides 331 

Lepra 335 

CLASS VII. NEUROSES. 

Pruritus 344 

Anaesthesia ' 351 






CONTENTS. XI 

CLASS VIII. DISEASES OF THE APPENDAGES. 

PAGE 

i. Diseases of the Nails 353 

2. Diseases of the Hair and Hair Follicles 

Hypertrichosis 360 

Atrophia Pilorum Propria 369 

Fragilitas Crinium 370 

Monilethrix 371 

Piedra 372 

Trichorrhexis Nodosa 372 

Tinea Nodosa 373 

Canities 374 

Alopecia 376 

Alopecia Areata 380 

Folliculitis Decalvans 388 

Sycosis Vulgaris 388 

3. Diseases of the Sebaceous Glands. 

Seborrhcea 392 

Asteatosis 396 

Milium 396 

Steatoma 397 

Comedo 398 

Acne 400 

Acne Varioliformis 414 

Acne Rosacea 415 

4. Diseases of the Sweat Glands. 

Hyperidrosis 422 

Anidrosis 426 

Bromidrosis 426 

Chromidrosis 428 

Haematidrosis 429 

Uridrosis 431 

Phosphoridrosis 43 1 

Sudamen 432 

Hydrocystoma 432 

Granulosis Rubra Nasi 433 

Miliaria 433 

Hydradenitis Suppurativa 434 



Xll CONTENTS. 

CLASS IX. PARASITIC AFFECTIONS. 

A. Diseases Due to Vegetable Parasites. 

page 

Favus 435 

Tinea Trycophytina 437 

Ring-worm of the General Surface 440 

Ring- worm of the Scalp 441 

Ring-worm of the Bearded Region 446 

Tinea Imbricata 449 

Tinea Versicolor 449 

Erythrasma 452 

Actinomycosis 452 

Mycetoma 454 

Blastomycetic Dermatitis 454 

B. Diseases Due to Animal Parasites. 

Pediculosis 455 

Pediculosis Capillitii 456 

Pediculosis Vestimentorum 458 

Pediculosis Pubis 460 

Animal Parasites of Minor Importance Attacking the Skin 461 

Scabies 463 

Animal Parasites of Minor Importance Penetrating the Skin 467 

Index 473 



DISEASES OF THE SKIN. 



ANATOMY OF THE SKIN. 

For the purpose of study the skin may be divided into three 
parts: the epidermis, the corium and the subcutaneous connec- 
tive tissue. The latter is, strictly speaking, not a portion of the 
true skin, but is commonly considered with it for purposes of 
convenience. 

THE EPIDERMIS. 

The epidermis is divided for convenience sake into five layers 
which are named from within outwards, (i) flie basal layer or 
stratum germinativum; (2) the prickle cell layer or stratum Mal- 
pigJiii; (3) the stratum granulosus; (4) the stratum lucidum; and 
(5) the stratum corneum. These layers may be considered, not so 
much as special layers, as stages in the gradual evolution of the 
basal columnar cells, until they become corniried squamae or 
scales.* 

The basal and Malpighian layers are next to the corium 
and dip down between the papillae to form the interpapillary 
processes; consequently, in vertical sections, the dividing line 
between epidermis and corium presents a wavy appearance. 
The Malpighian layer varies in thickness in different localities. 
It is thickest on the palms and soles and thinnest over the elbows, 
forehead, and cheeks. 

The Basal Layer or Stratum Germinativum is the deepest 
layer of the epidermis and consists of a row or, occasionally, 
of two rows of regular columnar cells, with oval nuclei, arranged 

* This description of the minute anatomy of the skin is largely taken from Mac- 
leod, Handbook 0} the Pathology of the Skin, London, 1903, with occasional 
references' to Duhring's Cutaneous Medicine, Pt. i, Philadelphia, 1895. 

1 



DISEASES OF THE SKIN. 




Fig. i. — Section of skin showing various layers. 

a, Stratum corneum. b, Stratum lucidum. c. Stratum granulosum. d, Stratum mal- 
pighii or prickle cell layer, e, Stratum germinativum or basal layer. f, Blood vessels, g, 
Papillary layer of the corium. h, Reticular layer of the corium. i, Coil or sweat gland. 
I, Subcutaneous tissue, k, Tactile corpuscle. 



THE EPIDERMIS. 3 

vertically to the wavy line between the epidermis and the corium. 
The cells of this layer are united together by fine protoplasmic 
threads which pass from cell to cell across the interepithelial 
spaces. Towards the corium the protoplasmic fibres are collected 
into tufts which give a denticulate appearance to the line of 
demarcation between the two layers. The germinal layer is 
the one from which the whole of the epidermis is developed. 
Its cells are constantly dividing by mitosis, and the daughter 
cells do not divide in the normal state but are simply pushed 
forward to the surface by new layers of cells forming beneath 
them and gradually evolving into horn cells. The pigment of 
the skin is found in the form of numerous brownish pigment- 
granules scattered around the nuclei of the cells of the basal 
layer. 

The Prickle Cell Layer or Stratum Malpighii. Above the 
basal layer the cells are polygonal in shape and, instead of being 
arranged in rows, tend rather to be built up in the form of a 
mosaic. Toward the surface they become more and more 
flattened. Their nuclei are roundish in shape in the centre 
of the layer and oval as it merges into the granular layer. These 
cells are peculiar in that their network of spongioplasm stretches 
beyond the cells in the form of fine radiating protoplasmic threads 
which pass across the intercellular spaces to be continuous with 
the spongioplasm of neighboring cells. The whole of the cells of 
this layer are, therefore, in organic connection with one another. 
It was formerly supposed that each of these cells was surrounded 
by a set of protoplasmic spicules like the projections on a prickly 
pear and hence the name " prickle cell" layer still given to this 
layer. Between the prickle cells there are lymph spaces which 
are bridged over by the protoplasmic fibers.* 

The Granular Layer or Stratum Granulosum. Towards the 
surface the prickle cell layer of the epidermis merges into a 

* Herxheimer has described certain corkscrew-like fibres occurring between the 
cells of the stratum Malpighi and the basal layer. They run parallel to the long 
axis of the cell for the most part. Similar fibres are found occasionally between 
the cells of the granular and horny layers and between the cells of the inner root- 
sheath of the hair follicle. The exact nature of these, "Herxheimer's spirals," has 
not been determined, observers differing as to their character and significance. 



4 DISEASES OF THE SKIN. 

layer consisting of two or three rows of flattened cells contain- 
ing numerous granules which is known as the stratum granu- 
losum or granular layer. These cells lie more closely together 
than the prickle cells of the Malpighian layer, their prickles are 
shrunken, and their nuclei are shriveled and mulberry shaped 
and appear to have shrunk away from the protoplasm of the 
cell so as to leave a nuclear space. The granules consist of a 
substance having relation to the process of cornification and, 
hence, termed by Unna " keratohyalin." 

The Stratum Lucidum. Between the granular layer and the 
stratum corneum there is a thin intermediate layer of cells which 
is known as the stratum lucidum because, in unstained sections 
of the skin of certain parts, as the sole of the foot, the layer may 
be seen as a semi-transparent line across the section, resembling 
a narrow oily streak across a sheet of paper. The cells of this 
layer are larger and more irregular in shape than those of the 
stratum granulosum, their prickles are more shrunken and 
their nuclei have still further shriveled, and may sometimes 
be represented only by a mass of debris in the nuclear spaces. 
The keratohyalin granules have now disappeared and been 
replaced by a homogeneous oily-looking subsance, known as 
eleidin, which is present, not only within but between the cells, 
and which is the chief characteristic of this layer. It is not 
stained by osmic acid and is, therefore, not fat. The cells of 
the stratum lucidum, however, stain with osmic acid, showing 
that they contain fat as well as eleidin. 

The Stratum Corneum. The stratum corneum is the most 
superficial layer of the skin. It is the layer which we see and 
touch, and is the " first line of defense" in resisting external 
mechanical assaults and the entrance of toxins and micro-organ- 
isms. This layer varies greatly in thickness in different parts 
of the skin. On the palms of the hands it averages 4. mm., 
and on the soles of the feet it may reach 5 to 6 mm., in thickness. 
It is especially thin upon the face and upon the flexor surface 
of the extremities. On the flexor surface of the forearm, for ex- 
ample, it has an average thickness of .02 mm. 



THE CORIUM. 5 

The stratum corneum is composed of epidermal cells which 
have undergone the process of cornification or keratinization. 
The individual cells are now known as "horn cells." The 
most perfect horn cells are situated immediately above the stra- 
tum lucidum, while towards the surface of the body alterations 
from drying and pressure produce the flattened degenerate type 
of horn cell known as the "squame," which is rubbed off con- 
stantly by the friction to which the skin is subjected. The 
perfect horn cell is polygonal in shape, faceted on the surface 
from pressure, and presents a space in the centre from which 
the nucleus has completely disappeared. The hyaloplasm and 
eleidin of the cell have given place to a fatty or waxy substance, 
and the peripheral portion of the spongioplasm has become 
transformed into a highly resistant substance called keratin. 
Macleod believes that these horn cells are held together, not by 
intercellular substance, but by a sort of felting together of the 
keratinized epithelial fibres. It is this which makes this layer 
so tough and resistant and which prevents its rupturing in the 
formation of vesicles and bullae. When the cornification is 
imperfect and the intercellular bridges do not become trans- 
formed into keratin, the defective horn cells become separated, 
air appears between them, and they desquamate in variously 
sized scales. 

The existence within the horn cells of the fat or waxy material 
makes the stratum corneum a waterproof coating to the body, 
preventing the absorption of water and substances dissolved 
and suspended in it. 

THE CORIUM. 

The corium is the dense fibrous layer of the skin which is 
situated beneath the epidermis. It supports and protects the 
hair follicles, glands, nerves, nerve terminations, blood-vessels, 
lymphatics and fat cells, and it is to this layer that the skin owes 
its strength and elasticity. 

The corium is divided into two layers, the superficial or papil- 
lary layer and the deep or reticular layer. Beneath the reticular 



6 DISEASES OF THE SKIN. 

layer is the subcutaneous tissue, derived, however, from the 
same embryonic layer as the corium and in the view of many 
observers a part of the latter. 

In the papillary layer, the bundles of white fibrous tissue are 
thin, loosely packed together, and tend to have a vertical direc- 
tion. In the reticular layer these bundles are more numerous than 
in the papillary layer; they are also thicker and split and cross 
each other in various directions, forming a complicated network. 

In the subcutaneous tissue the bundles unite to form the 
large trabecular and septa which separate and support the fat 
lobules. 

THE PAPILLARY LAYER. 

The papillary layer is that upon which the epidermis lies and 
upon which the latter depends for its nutrition. There is no 
real demarcation between the two layers, but the cells of the 
basal layer of the epidermis are bathed by the same lymph 
which circulates in the lymphatic spaces between the fibrous 
bundles of the papillary body. 

The papillce are the conical projections of the corium. In 
some are found the terminal capillary loops, these are called 
vascular papillce. Others contain certain nerve terminations 
and are known as sensory papillce. The papillae are usually 
single, or, more rarely, there may be two or more upon a com- 
mon base, forming a compound papilla. The papillae are situated 
on ridges of varying heights. Sometimes there are two rows 
of papillae on a ridge. These ridges are particularly well marked 
on the finger-tips where their wavy outlines vary so much in 
different individuals as to form a well known element in the 
scientific identification of criminals. 

THE RETICULAR LAYER. 

The papillary layer merges into the reticular layer without 
line of demarcation, the difference in these strata consisting in 
the arrangement of the connective tissue bundles. The reticular 
portion is looser in texture, being made up of fasciculi of connec- 



BLOOD-VESSELS OF THE SKIN. 7 

tive tissue which decussate more obliquely and give it a plex- 
iform arrangement as already mentioned. 

The thickness of the corium varies greatly in different parts 
of the body. In the infant it is thin, the subcutaneous tissue 
being relatively very thick. In the adult it is thickest upon the 
soles, palms, buttocks and entire back, and thinnest upon the 
eyelids, prepuce, glans penis, inner surface of the labia majora 
and some other points. 

THE SUBCUTANEOUS CONNECTIVE TISSUE. 

The subcutaneous connective tissue is to be viewed as part 
of the true skin, the latter merging into it. It is made up of 
variously sized bundles or fasciculi of connective tissue which 
cross one another at different angles, thus forming a rhomboidal 
network. The meshes, though variable in size, are generally 
larger, the inter fascicular spaces, therefore, being well defined. 
It possesses a much looser and coarser structure than the corium, 
and contains in most regions an abundance of fat. In some 
regions, however, as the eyelid, the latter is wanting. Warren 
has described columns of this tissue as passing in a nearly vertical 
direction from the adipose tissue to the bases of, especially, the 
finer hair follicles. 

Large blood-vessels pass through the subcutaneous connective 
tissue, giving off branches to the corium and the structures con- 
tained within it. Pacinian corpuscles, nerve trunks, lymphatics, 
sweat glands and the lower part of the hair follicles of deeply 
seated hairs are all found here. Above, it blends intimately 
with the corium, while its deeper layers are connected with the 
superficial fasciae of muscles and the periosteum. 

The subcutaneous tissue serves as a pad or cushion on the 
outside of the body and also acts as a temperature regulator of 
the body, being a poor conductor of heat. 

BLOOD-VESSELS OF THE SKIN. 

Both the corium and the subcutaneous tissue are highly vas- 
cular, having numerous blood-vessels throughout their structure 



5 DISEASES OF THE SKIN. 

in the form of trunks, branches and capillaries. Arterioles 
for the sweat and sebaceous glands and for the hair papillae 
also exist. The arteries and veins anastomose in their final ter- 
mination. 

Two parallel horizontal plexuses exist, one superficial, in the 
upper layers of the corium, the other deep, in the subcutaneous 
tissue. The main vessels of the corium ascend from the sub- 
cutaneous tissue and give off branches laterally in all directions, 
richly supplying the glands and hair follicles, as well as the other 
structures in the corium. In the papillary layer a delicate and 
highly organized plexus of capillaries exists, affording an abun- 
dant supply to this region. The papillae receive capillary loops 
which run through their centre or at their sides parallel to their 
long axes. 



L r-> 



LYMPHATICS. 

In the subcutaneous tissue the lymphatics are large vessels 
upon which the rudiments of a muscular apparatus have been 
observed. In the upper strata of the corium they form a net- 
work of denser and much smaller vessels. Valves occur in the 
branches coming up from the deeper network. Unna believes 
that the greater part of the lymph which circulates through the 
skin is taken up by the veins which are much larger than the 
arteries in this locality. The juice spaces are those lymphatic 
channels which do not possess an obsolutely free outflow into 
distinct lymphatic vessels lined with endothelium, whether 
they are deprived of independent walls, as is usually the 
case, or are provided with them. Lymphatic vessels, on the 
other hand, may be defined as those canals from which a free 
outflow into the blood takes place. Juice spaces exist in the 
epidermis (a tissue destitute of blood-vessels), where they 
occur embedded in the interspinous passages of the prickle cell 
layer. 

The papilke are freely traversed by juice spaces. The excretory 
ducts of the coil glands, the sebaceous glands, the prickle-cell 
layer of the hair follicle, and the hair bed have the same inter- 



NERVES. 9 

epithelial juice spaces as the epidermis. The oblique muscles 
of the skin and the coils of the coil glands float in distended lymph 
spaces. In the case of the coil glands they supply material for 
this glandular secretion. 

The lymph flows to the epidermis mainly from the apices 
of the papillae, thence spreading in all directions through the 
epidermis and returning to the corium by the way of the in- 
terpapillary depressions, through the sweat pores. 

NERVES. 

In the skin both medullated and non-medullated nerve fibres 
are present. The medullated fibres pass into the corium with 
the blood-vessels from the more superficial of these fibres. Fine 
non-medullated fibres pass up between the prickle cells of the 
epidermis and between the cells of the corresponding layer of 
the hair follicles. A few of the medullated fibres terminate in 
the special end organs known as the tactile corpuscles, the touch 
cells of Merkel and the Pacinian bodies of the subcutaneous tis- 
sue. It is probable that the non-medullated nerves supply the 
muscular fibres of the arrectores pilorum, the sweat coils and 
the blood-vessels. The nerves of the skin are numerous in the 
palms of the hands and the soles of the feet, especially in the 
tips of the fingers and toes — regions where sensation is particu- 
larly acute. 

In addition to sensory nerves the skin is said to possess motor 
nerves on the smooth muscles of the skin and on all glands 
which have a muscular layer. Of the vaso-motor nerves of the 
skin but little is known with any degree of certainty. They 
are particularly abundant about the arterioles of the skin and 
exert an influence upon the vascular, muscular, and glandular 
cutaneous systems, causing increase or diminution of the 
circulation, as in flushing or blanching of the skin, in contraction 
of the muscles as in cutis anserina or " goose flesh," or when 
the hairs "stand on end" and in profuse sweating, local or, more 
rarely, general. 



IO DISEASES OF THE SKIN. 



MUSCLES. 



The muscles of the skin consist of the arrectores pilorum, 
the layers of involuntary muscular fibres, and the voluntary mus- 
cular fibres. 

The arrectores pilorum, or arrector muscles of the hair, are 
involuntary muscles. They arise from the fibres of the papillae 
and are inserted into the fibrous coat of the hair follicle below 
the sebaceous gland. (See Fig. 2.) They are situated in the 
oblique angle of the follicle so that on contracting they make 
the follicle more vertical and so cause the hair to become 
erect. The condition known as "goose skin" which may result 
from the action of cold is due to the contraction of these 
muscles. 

Muscular layers or membranes are found in the dartos of the 
scrotum, areolae of the nipples, and in the eyelids. They are 
stimulated to contract by cold and in contracting they cause 
a puckering of the skin. 

Voluntary muscular fibres, or striated muscular fibres, pass 
from the platysma and from the muscles of expression of the face 
into the corium, so that when these muscles contract a wrinkling 
of the skin is produced. 

PIGMENT. 

In white races very little pigment is present in the skin, except 
in the pigmented regions, such as the areolae of the nipples, ax- 
illae, scrotum and around the anus. The color of the skin depends 
more on the vascular condition and on the subcutaneous fat. 
The stratum corneum has a grayish or ground-glass tinge, while 
the rete is yellowish. In the white races, pigment, except in the 
hairs, does not appear till after birth, while, in colored races, some 
pigment is present even considerably earlier. 

The pigment-granules in white races are situated chiefly in 
the epithelial cells of the basal layer of the epidermis. In dark 
races the pigment extends up as far as the transitional layers 
of the epidermis. ' 



SEBACEOUS GLANDS. 



II 



SEBACEOUS GLANDS. 

The sebaceous glands are small, sac-like or racemose glands 
seated in the corium, usually in connection with the hair follicles, 
(see Fig. 2) but also independently of hairs, in such situations 




Fig. 2. — Section of hair and hair follicle from Ziemssen. Showing general 
arrangement of parts. 

1. Mucous layer of the epidermis. 2. Basal pigment cells. 3. Papillary layer of the 
corium. 4. Continuation of basal rete cells. 5. Sebaceous gland. 6. Muscle of the hair. 
7. Nerves. 8. Blood corpuscles. 9. Transverse section of blood-vessel. 10. Root of hair. 
11. Hair follicle. 12. Papillary vessels. 13. Papilla of hair. 14. Nerves. 15. Medullary 
substance of hair. A. The hair. B. Stratum corneum of the epidermis, C. Stratum 
lucidum of the epidermis. D. Stratum granulosum of the epidermis. E. Sebaceous gland. 
F. Panniculus adiposus. 16. Cortical substance of the hair. 17. Cuticle of hair. 18. Henle's 
layer of inner root sheath. 19. Huxley's layer of inner root sheath. 20. Outer root sheath. 

as the free borders of the lips, toward the angles of the mouth, 
on the labia minora, the areolae of the nipples and the caruncles 
of the eyes. 

Accompanying the larger hairs the glands are generally situated 
on the oblique side of the hair follicle into which they open by 



12 DISEASES OF THE SKIN. 

a short duct. The glands connected with the large hairs, as 
those of the beard, are relatively small, while those belong- 
ing to the lanugo hairs are large, as on the nose. The 
largest sebaceous glands are those about the nose, concha 
of the ear, scrotum and areola of the nipple. In some cases 
the gland is made up of a single saccule, in other cases there may 
be several or even as many as twenty or more. The saccules 
open into a common duct which pours its contents into the follicle 
to lubricate the hair. The glands unconnected with the hairs, as 
those of the nipple, open directly on the surface of the skin. 

Each saccule or acinus of the sebaceous gland has a connective 
tissue covering inside, which is a basement layer of flat cells 
on which are built up layers of cubical cells with round or oval 
nuclei. Towards the centre these cells have undergone a fatty 
metamorphosis which results in the exudation of oil globules 
collecting in the lumen of the duct and forming a whitish mass. 
When this reaches the hair follicle it becomes mixed with the 
epithelial debris and partly solidifies to form sebum. 

Sebum, the product of the sebaceous glands, is an oily, fatty 
semi-fluid amorphous substance of a yellowish color, and consists 
of olein, palmitin, stearin, the fatty acids, cholesterin crystals, 
chlorids and phosphates of the alkaline earths, organic salts, 
water and occasionally butyric or caproic acid. Mixed up with 
these are epidermal nuclei, debris of cells and a few horn cells. 

The Meibomian glands are embedded in the free borders 
of the eyelids and are the largest sebaceous glands met with. 
They differ from other sebaceous glands chiefly in their elong- 
ated form. The Tysonian glands are found upon the glans 
penis and upon the inner surface of the prepuce. The smegma 
which forms in this locality and which was formerly supposed 
to be the secretion of these glands is now believed to be mainly 
an exfoliation of the horny layer of the epidermis. 

THE SWEAT GLANDS. 

The sweat or coil glands are distributed over the skin of the 
whole body except that of the glans penis, margin of the lips 



THE SWEAT GLANDS. 1 3 

and the nail bed. In the external meatus of the ear they are 
found as ceruminous glands, on the eyelids they are known as 
the glands of Moll. 

The sweat glands are large and small. The large glands are 
met with in the axillae and groins and around the anus, while 
the small variety are distributed generally over the skin. In the 
small glands the diameter of the coils averages 3 mm. to 4 mm.; 
in the large large glands of the axillae and scrotum it may measure 
1 mm. to 3 mm. 

The glands vary greatly in number in different individuals. 
They are said to average 2800 per square inch on the palms of 
the hands, where they are more numerous than elsewhere, except 
the soles of the feet. 

Structure. The sweat or coil glands are simple tubular glands 
composed of a body, consisting of two or more turns of a tube, 
and forming a coil which is situated either in the reticular layer 
of the corium or in the subcutaneous tissue; and a duct which 
traverses the corium in a spiral manner. (See Fig. 1.) 

The coil or body is a flattened or roundish structure usually 
composed of several turns of the tube. Near the blunt end it 
consists of a single layer of cylindrical epithelial cells with oval 
nuclei. Here and there a connective tissue cell may be found 
wedged in between two of these cells, thus allowing an inter- 
change of the gland contents with the lymph of the neighboring 
tissue spaces. Outside these epithelial cells are involuntary 
muscle cells, and outside the muscular layer a basement mem- 
brane has been described. 

Occasionally brown or yellow pigment-granules may be pres- 
ent in the epithelial cells of the coil. These are secreted with 
the sweat and may color it. 

The excretory duct is made up of two well-defined portions 
which differ entirely in their structure, namely, (1) the part 
in the corium, and (2) the channel through the epidermis. 

The part of the duct which passes through the corium like 
a corkscrew has a uniform caliber, the epithelium similar to 
that in the coil and consists of two or three layers of cubical cells 



14 DISEASES OF THE SKIN. 

with a fibrous coating. There is no muscular coat to the duct. 
A plexus of blood-vessels surrounds the coil and extends up the 
duct. Small nerve fibres pass to the muscle cells of the coil. 
On reaching the epidermis the duct proper may be said to end, 
for it is represented simply by a spiral cleft between the prickle 
cells of an interpapillary process. Toward the surface this 
cleft opens out into a funnel-shaped opening, the pore. 

THE HAIR. 

Hairs are present on all parts of the human skin except that 
of the palms of the hands, soles of the feet, red parts of the 
lips, glans penis, inner surface of the prepuce, inner surface of 
the labia majora and dorsal aspects of the ungual phalanges of 
the fingers and toes. 

The number of hairs to a given area of skin has been variously 
estimated, averaging, at the vertex of the scalp three hundred to 
the square centimeter, forty-four on the beard of the chin and eight- 
een on the back of the hand. Wilson estimated that there were 
about one hundred and twenty thousand hairs on the whole 
scalp but the number varies considerably in individuals and 
according to the color of the hair. 

The color of the hair is chiefly due to pigment-granules in 
the cortex, but is also dependent, to some extent, upon the diffuse 
color of the protoplasm of the hair cells and upon the presence 
of air between the hair cells. The pigment and diffuse coloring 
matter diminish with advancing age, and by shrinkage and atrophy 
of the hair cells and the presence of air between them the white 
hair of old age is produced. 

Aside from the scalp the hairs are thickest in the beard and 
about the genitalia, and thinnest on the trunk and limbs where 
they form the lanugo. 

THE HAIR FOLLICLE. 

The microscopic anatomy of the hair and hair follicle is some- 
what intricate and its study has been made more so by a com- 
plicated terminology. Essentially, however, it is as follows: 



THE HAIR FOLLICLE. 



15 



The hair follicle is to be regarded as a simple invagination of 
the skin, enveloped by a condensed layer of connective tissue. 
Considered from within outwards, the follicle in its upper third 
has epidermal layers similar to and continuous with those of 

imp. 

mm 




Fig. 3. — Section of normal hair much magnified and showing minute structure. 

Hair. .4. Cortex. B. Root. C. Cuticle. D. Medulla. 

Papilla. H. Papilla, showing connective tissue fibres and vascular loops. 

Hair Follicle. E. External connective tissue layer of the hair follicle. F. Middle 
fibrous layer of the hair follicle. G. Internal hyaline or vitreous layer of the hair follicle. 
/. External root sheath. /. Internal root sheath. 

the epidermis — namely, a horny layer, transitional layers, a prickle 
cell layer and a basal layer. In the lower two-thirds the horny 
and transitional layers disappear and only the prickle cell and 



l6 DISEASES OF THE SKIN. 

basal layers remain. The epidermic portion of the follicle 
is enveloped in a dense sheath of connective tissue derived from 
the corium. 

The continuation of the prickle cell layer of the epidermis in 
the hair follicle is generally known as the external root sheath. 
It consists of polygonal prickle cells with round nuclei which 
are arranged in several layers but which form only a single layer 
of cutical cells near the papilla. This layer usually comes out 
when the hair is epilated and the cells may be seen adhering 
to it. 

Between the prickle cell layer and the hair there is a some- 
what complicated structure known as the internal root sheath. 
It occupies the lower two-thirds of the follicle. On the inside 
of the internal root sheath there is a cuticle formed of a single 
layer of elongated cells with their long axes divided downwards 
and inwards. These cells fit into the cuticle of the hair, which 
have an opposite direction. Owing to the close union of the 
two cuticles, it is almost impossible to epilate a hair without 
pulling out part of the root sheath. 

Outside the external root sheath is the connective tissue layer of 
the hair follicle. It is composed of an external layer of connective 
tissue cells and fibres, blood vessels and nerves, a middle layer 
of fibrous bundles arranged circularly, and an internal layer 
of an apparently homogeneous character known also as the 
"hyalin" or "vitreous" layer. 

THE PAPILLA. 

The papilla of the hair is a differentiated process of the 
corium, analogous to the papillae of the papillary layer. It is 
conical in shape, consists of connective tissue fibres and cells 
supporting a vascular loop and medullated nerves. 

MINUTE STRUCTURE OF THE HAIR. 

The hair consists of a shaft or stem which widens out at the 
lower end of the hair follicle into a bulbous extremity known as 
the root of the hair. The greater portion of the shaft is formed 



THE ROOT OF THE HAIR. 1 7 

by the cortex, in the centre of which there is a more variable 
structure known as the medulla. The hair is protected externally 
by a sheath or cuticle formed of a single layer of cells. 

The cuticle is made up of quadrilateral flat cells arranged in 
an imbricated manner, overlapping one another like slates, and 
have their long axes directed upwards and outwards at an acute 
angle to the axis of the shaft. 

The cortex composes more than two-thirds of the shaft when 
the medulla is present and the whole of it in the absence of the 
medulla. It consists of bundles of spindle-shaped cells which 
give it a fibrillated appearance. The cells contain diffuse color- 
ing matter of a yellowish or reddish tinge. Between them, and, 
occasionally within them, pigment-granules may be found. 

The medulla forms the core of the hair and extends to near 
the tip. By transmitted light the medulla appears as a dark 
streak in the centre of the shaft from the presence of air in and 
between the cells. The medulla is made up of rouleaux of 
plates composed of three or four flattened cells. Medullar only 
occur in the hairs of the scalp, beard, axillae and pubes. 

THE ROOT OF THE HAIR. 

The hair root is the bulbous lower extremity of the shaft 
It is indented at its upper end by the upgrowing, conical, vascu- 
lar process of connective tissue known as the papilla. The 
cells composing the root present, especially near the papilla, 
almost their original characters and are not differentiated into 
the appearance they present in the shaft. 

The cuticle oj the root consists of a single layer of cells, which, 
near the papilla, are cubical in shape and have their axes directed 
downwards and outwards. Further along they are directed hor- 
izontally and finally upwards and outwards. 

The extension of the cortex in the root is composed of polyg- 
onal cells with well-marked nuclei, and it is only at the upper 
limit of the bulb that they assume their fusiform shape and 
that the fibrous appearance of the cortex becomes evident. These 



15 DISEASES OF THE SKIN. 

cells contain diffuse coloring matter and occasionally pigment- 
granules. 

The medulla of the root is formed of cubical non-pigmented 
cells containing granules of keratohyalin. 

NAILS. 

The nails are hard, horny, elastic, translucent structures 
which are embedded in the corium upon the last phalanges of 
the fingers and toes. The uncovered part of the nail is called 
the body, the posterior portion embedded in and concealed 
by the groove is called the root. Around the lateral and posterior 
edges of the nail, at the line where the true skin joins the nail, 
there exists a well-defined groove, the nail groove. That portion 
of the skin which arises from the groove and which covers in the 
nail as a fold is known as the nail fold or nail wall. The epon- 
ychium or nail skin is a thin layer of cuticle which proceeds 
from the nail fold and, extending forward, covers as a film the 
beginning of the body of the nail to a variable, but, usually, very 
short distance. The epidermis beneath the body of the nail is 
called the hyponychium, that bordering the entire nail the peri- 
onychium. Upon the outer surface of the nail are more or less 
marked but minute striae or minute ridges running parallel with 
the long axis of the nail. 

The lunula or semi-lunula is the little whitish half-moon-shaped 
or crescentic spot which exists in front of the nail fold. It is 
most distinctly defined upon the thumb and is often not defined 
or wanting upon the toes. 

The nail is a pecular metamorphosed portion of the epidermis 
and is made up of two layers in the same manner as is the epi- 
dermis of the skin, a soft mucous layer and a hard horny layer, 
the latter composing the nail proper. 

THE NAIL BED. 

The nail bed i-s that portion of the corium anterior to the 
matrix upon which the nail substance rests. It consists of sub- 



THE MATRIX. 1 9 

cutaneous connective tissue, corium and mucous layer of the 
epidermis. 

THE MATRIX. 

The matrix or germ layer of the nail corresponds to the mucous 
layer of the epidermis. It occupies the posterior portion of the 
nail bed, lying wholly or partly within the nail fold, and is the 
exclusive seat of the formation of the nail. 

The nail grows by the generation of the cells of the mucous 
layer at the root. The horny cells are pushed forward by the 
new mucous cells, cornification taking place as in the horny 
layer of the epidermis of the skin. 

The nail, when uncut, grows out a certain length and then wears 
away by natural desquamation of the cells. When carefully 
tended, as in China and Korea, it may grow to a length of two 
inches or more. The nails grow more rapidly in summer than 
in winter and more rapidly in children than in adults. The 
time required for the growth of the nail from the lunula to the 
free edge on the fingers is variously given as from 108 to 168 days, 
varying, probably, according to the condition of the general 
nutrition, etc., of the individual. Quain gives the growth as one 
thirty-second inch in a week. 

PHYSIOLOGY OF THE SKIN. 
THE SKIN AS A PROTECTIVE ORGAN. 

The skin is a protective organ in a double sense. It guards 
the economy from external agents, as heat and cold, chemical 
and mechanical injury. It serves to enclose and protect the 
subcutaneous structures and fluids of the body. 

THE SKIN AS A SENSORY ORGAN. 

The skin is an organ of common sensation conveying feelings 
or sensations of various kinds to the nerve centres. Through 
tactile sensibility, knowledge is obtained of various objects with 
which we come in contact. The vaso-motor nerves play an impor- 
tant part in the physiology and pathology of the skin. Pain 



20 DISEASES OF THE SKIN. 

and the temperature sense are also functions of the cutaneous 
nerves. 

The skin acts as a regulator of bodily heat and aids in pre- 
serving a constant temperature of the blood by contraction 
and exhaustion of peripheral vessels. 

THE SKIN AS A RESPIRATORY ORGAN. 

The skin, like the lungs, absorbs oxygen and gives forth car- 
bonic acid and water. The quantity of oxygen absorbed by the 
skin, however, is almost infinitesimal. The quantity of carbonic 
acid exhaled is calculated variously by different authorities 
from 2.23 grams to 30 grams in 24 hours. Increase in the tem- 
perature of the surrounding atmosphere, muscular work and 
other circumstances involving the quantity of blood sent to the 
skin raise the volume of carbonic acid exhaled. 

The water exhaled from the skin appears as invisible vapor, 
"insensible perspiration" or visible vapor "sensible perspira- 
tion." It may amount to 600 grams in 24 hours, or double that 
given off by the lungs. 

Experiments have been made from time to time in coating 
the cutaneous surface with various impermeable dressings, such 
as varnish, oil, paint, adhesive plaster, colodion and tar. In 
man these experiments have not resulted seriously, except when, 
as in the case of tar, some toxic ingredient of the impermeable 
covering has been absorbed. 

THE SKIN AS A SECRETORY ORGAN. 

The most important function of the skin is that of secretion, 
which is to be considered under the heads of (1) sweat and (2) 
sebaceous secretions. 

Sweat Secretion. The secretion of sweat takes place in the 
coil of the sudoriparous, sweat or coil gland. The amount 
of sweat secreted varies in different regions. The palms as a 
rule give off most, then the soles, face, neck, axillae, genital 
region, arms and forearms. 



THE SKIN AS A SECRETORY ORGAN. 21 

The sweat is a watery or fatty, colorless, clear fluid, with an 
alkaline or acid reaction, according to circumstances. It pos- 
sesses a salty taste and a characteristic odor varying with the 
individual and the circumstances, and which is due to the presence 
of volatile fatty acids. In addition to sweat, the coil glands at 
times secrete oil. 

Perspiration varies in different persons, the average amount 
of water poured out is, as was said above, about twice the weight 
of that secreted by the lungs. The effect of temperature on the 
secretion is marked. Vascular or muscular activity acting on 
the blood pressure and the internal use of warm water in quan- 
tity produce an increase in the secretion. The action of certain 
drugs on the sweat secretion is marked. Some, as pilocarpin, 
increase the flow, others, as atropin, diminish it. 

The relation between the sweat glands and the kidneys is 
complementary one to the other. Their action in a given case 
is in inverse ratio. When the skin is active, as in summer, 
the kidneys separate less water, while, in winter, when the cuta- 
neous capillaries are chilled, the urinary secretion is increased. 
Urea is a normal constituent of sweat to the proportion of about 
o.i per cent., though variations occur. 

The Sebaceous Secretion. The product secreted by the seba- 
ceous glands is designated sebaceous matter, or sebum. It is a 
fatty substance, and in healthy persons, within the glands, is a 
fluid or semi-fluid substance of variable consistence tending to be- 
come firmer and of a fatty or cheesy consistence as it reaches the 
duct. In certain localities where the glands are large, as on the 
nose and neighborhood, the sebum can sometimes be expressed 
in firm plugs. Commonly it exists on the skin as a greasy or 
oily coating. 

Chemically, sebum consists of fluid olein and solid palmitin, 
fats, cholesterin soaps, an albuminoid, and the alkaline chlorides 
and phosphates. Microscopically the sebum shows free fat, 
fatty cells and cell debris, cholesterin crystals and epidermic 
scales. The vernix caseosa of the new born and the smegma 
prceputialis are similar in composition. Cerumen, or ear wax, is 



2 2 DISEASES OF THE SKIN. 

a mixture of the product of the sebaceous and coil glands. The 
secretion of the Meibomian glands is sebum. 

ABSORPTION. 

The whole structure of the skin and its function as a protective 
organ are directed against the absorption of alien substances. 
The horny epidermis and the oily covering with which it is 
endowed by the sebaceous and coil glands serve to resist the pen- 
etration of substances of any sort. There is, however, a certain 
faculty of absorption in the uninjured skin, chiefly of volatile and 
penetrable substances mixed with fatty matters. Ointments 
containing iodine, belladonna, mercury, etc., when thoroughly 
rubbed into the skin carry a portion of their ingredients into the 
economy. Substances of a similar character are also absorbed 
to a slight extent in the course of prolonged immersion in watery 
solutions. 

But when the corneous layers of the skin are removed, as by a 
blister, absorption takes place with great rapidity. Applications 
made with the aid of a constant current of galvanic electricity 
are also absorbed (cataphoresis). 

SYMPTOMATOLOGY. 

The symptoms of skin disease are objective and subjective, 
and they may be limited to the disease itself or involve other 
parts or even the whole organism. 

At present we are concerned with the local manifestations 
of disease which are, generally and in the vast majority of cases, 
the only symptoms of importance. The general symptoms 
will be touched upon under the head of the various diseases 
in which they are manifested. 

OBJECTIVE SYMPTOMS. 

These comprise the elementary lesions of the skin and are 
divided into primary and secondary. A careful study of these 
lesions and perfect familiarity with their nature is an absolutely 



PRIMARY LESIONS. 23 

essential prerequisite to the study of diseases of the skin. With 
out a knowledge of the lesions going to make up an eruption the 
student can neither understand the description of a skin disease, 
nor convey an intelligent idea of it to another. 

PRIMARY LESIONS. 

Macules. Macules, maculae or spots, are variously sized, 
shaped and colored areas of abnormal skin, usually level and 
unaccompanied by elevation or depression. 

Macules may be of any size, from pin-head to palm-size or 
larger. They may be round, oval or irregular in outline and 
may be of almost any tint, depending on their origin, but usu- 
ally red, yellow, or brown. Macules may be due to several 
different causes: 

1. Hyperemia, arterial or venous. The eruption of erythema 
is an example. The color in these macules can be made to fade 
by pressure with the finger. 

2. Extravasation of blood and blood coloring matter. The 
eruption here is bright red at first and subsequently changes 
color like a bruise as absorption occurs. When these macules 
are in the shape of streaks they are called vibiccs ; when punc- 
tate petechia; when of larger size ecchymoses. 

3. The vessels of the skin may become permanently dilated 
or new vessels may form. The capillary ncevus is an example 
of the congenital from. The telangiectasis exemplifies the ac- 
quired form. 

4. Changes in the pigmentation of the skin either from excess 
or deficiency may occur as macules. In the former case we 
have as congenital, the mole, as acquired, lentigo or chloasma. 
Pigmentary macules may also occur as secondary to other in- 
flammatory changes, as in the stains left by lichen planus and 
certain syphilodermata. Diffuse pigmentations are not usually 
called macules but are spoken of simply as discolorations of the 
skin, as Addison's disease, etc. 

From loss of pigment arise the white spots known as vitiligo 
and leukoderma. 



24 DISEASES OF THE SKIN. 

Papules. Papules, or pimples, are circumscribed firm eleva- 
tions of the skin, varying in size from a pin-head to a split pea, 
and not visibly containing fluid. 

They may be round or angular at the base and in elevation 
convex or lenticular, acutely or bluntly conical or even flat at 
the top. In color they are some shade of red, white or yellow. 
They may be situated in the corium, in connection with the 
sebaceous glands, or about the hair follicles. They are of the 
following varieties: i. Inflammatory, as in eczema. 2. Com- 
posed of excessive cornification or accumulation of epidermic 
cells as in keratosis pilaris. 3. Produced by the accumulation 
of sebum as in milium or comedo. 4. Produced by hemor- 
rhage into hair follicles as purpura papulosa. 

Papules of the inflammatory variety may become transformed 
into other lesions, as vesicles or pustules, or may break down 
into ulcers, as in syphilis. They may also take on a scaly charac- 
ter in the course of their development. 

Vesicles. Vesicles are circumscribed, rounded or acuminate 
elevations of the epidermis, varying in size from a pin-point 
to a split pea, containing a clear or opaque fluid. They may 
arise directly on the surface as in miliaria; or on the top of an 
inflammatory base, diffuse or papular, as in eczema. 

Vesicles may be of different colors according as their contents 
are pure serum, sero-purulent matter or serum mixed with 
blood. They may be tense and firm, or flaccid. In some in- 
stances they are firm, sharply defined, and discrete, as in herpes 
zoster. In other instances, as in eczema, they tend to run to- 
gether and rupture readily, discharging their fluid over the surface. 

In form, vesicles are rounded, circumscribed, and either pos- 
sess a dome-like roof or are somewhat acuminated. They may 
have slight depressions on their summits as in varicella. Some- 
times they are irregular in outline. Anatomically, vesicles are 
situated between the horny layers, between the horny and mu- 
cous layers or in the mucous layer, or, in the case of lymph- 
angiectodes they are in the lymphatics of the corium. They 
may be single chambered, as in sudamen or multilocular, as in 



PRIMARY LESIONS. 25 

herpes zoster. The points to be observed are their size, color, 
contents, base, depth, mode of evolution, course, duration, the 
subjective symptoms, and, if the contents are evacuated, the 
condition of the skin beneath. 

Blebs. Blebs, or bullae, are irregularly shaped elevations of 
the epidermis, varying in size from a split pea to a goose egg, 
containing a clear or opaque fluid. When recent, they are of a 
pale yellowish color; when their contents become turbid they are 
whitish or yellowish; containing blood, they are reddish or brown- 
ish. Blebs usually have strong walls and are filled out and tense. 
They do not rupture easily, their contents drying up, but they 
may be flaccid as in pemphigus foliaceus. Blebs, as a rule, have 
no areola unless they contain pus, rising abruptly from the 
healthy skin, but they are usually preceded by a transitory red- 
ness. There is usually little or no sensation in blebs excepting 
those of dermatitis herpetiformis or when they are very exten- 
sive. The points to be observed are their size, shape, contents, 
duration, and, after rupture, the condition of the exposed surface. 

Pustules. Pustules are circumscribed, rounded, flat or acum- 
inated elevations of the epidermis varying in size from a pin- 
point to a finger-nail, containing pus. Pustules may originate 
directly or may develop from papules or vesicles. Often tran- 
sition forms of papulo-vesicles and vesico-pustules may be ob- 
served. They are usually opaque, yellowish or, when containing 
blood, brownish. Pustules have, as a rule, a red areola, some- 
times with induration, as in boils; sometimes they are round and 
convex, some are umbilicated, as in variola. Some are round and 
pointed, others, as in ecthyma, flat and irregular. Some pustules 
arise in the papillary layer of the skin, others in the sebaceous 
glands, as in acne, around the hair follicles, as in sycosis, or deep 
in the corium, as in boils. Their course is usually acute and they 
rupture, the contents drying up int6 a firm crust. If the process 
is deep enough a scar may be left. Pustules are often painful 
and tender, sometimes they are attended with burning but seldom 
with itching. The points to be noted are their size, shape, color, 
mode of evolution, anatomical position, base, course and sequelae. 



26 DISEASES OF THE SKIN. 

Wheals. Wheals, or pomphi, are rounded, flat, irregular, firm 
cedematous elevations of an evanescent character. They vary 
greatly in size from split pea to hand size or larger. In form 
they are bean shaped, ovalish, or tending to appear in raised 
lines or stripes. Their color is whitish, rosy or pinkish, often 
with a pale centre. They form very rapidly, often in a few mom- 
ents, and after lasting a greater or less time disappear as they 
came. 

Usually wheals are the result of angioneurotic irritation, exter- 
nal or internal, leading to the sudden outpouring of serum from 
the vessels ; this is followed immediately by a spasmodic contrac- 
tion of the capillaries. On the spasm ceasing, the released capil- 
laries take up the fluid again and the wheal subsides. Some- 
times blood is poured out, as in purpura urticans. 

Wheals are always attended with severe tingling or itching. 
The points to be noted are their size, color, mode of evolution, 
duration, sequelae, and their local or constitutional origin. 

Tubercles. Tubercles, or nodules, are circumscribed, solid, 
rounded or acuminate elevations of the skin varying in size from 
a split pea to a cherry. 

(It must be remembered that the term "tubercle" refers only 
to the form of the lesion and does not infer in any instance a re- 
lationship to pathological tubercle.) 

In shape tubercles are generally defined semi-globular, con- 
ical, flat or irregular in outline. They sometimes go on by per- 
ipheral extension and coalescence to an infiltration in diffuse, 
slightly elevated masses with sharply defined borders and flat- 
tish surface. When of inflammatory origin the color is usually 
red or brownish-red, but in other cases they may be of any color. 

Tubercles are produced in great part by the cellular neoplas- 
mata. Syphilis, leprosy, lupus and carcinoma may at times 
give rise to marked examples of tubercles. They undergo various 
changes in their evolution, according to their nature and cir- 
cumstances ; they are either absorbed, or break down and ulcer- 
ate, and are followed by scars, or they may establish themselves 
and remain permanent, as in molluscum fibrosum. 



SECONDARY LESIONS. 27 

In examining tubercles their size, shape, color, consistency 
and course are the points to be specially noticed. 

Tumors. Tumors are variously sized, shaped and constituted, 
firm or soft prominences or new growths of all kinds, from a pea 
and upwards in size, having their seat in the corium or subcu- 
taneous tissue. They may be of all sizes from a pea to an egg, 
or larger. They usually assume a rounded or globular form 
unless compound, in which case the form may be irregular. 
Tumors may be sessile, almost implanted in the skin, or they 
may be pedunculated, hanging even by a slender stalk. 

Their color may be the same as the surrounding skin or, when 
inflammatory, the color may be reddish of variable shade. The 
skin covering them may remain intact or may break down and 
form suppurating, bloody and crusted surfaces. Tumors are 
occasioned by a great variety of causes, as, for example, altera- 
tions in the sebaceous glands, various inflammations and new 
formations in the corium and connective tissue, and new growths 
of the blood-vessels and lymphatics. They may or may not be 
painful. 

SECONDARY LESIONS.* 

Crusts. Crusts are masses of dried, effete material composed 
of the products of cutaneous disease, irregularly shaped and 
sized, and usually yellowish or brownish in color. 

Several varieties of crusts are observed. Those resulting from 
an open serous discharging surface are yellowish or brownish- 
yellow, friable in consistence and, as a rule, without definite out- 
line or bulk, as in vesicular eczema; those following the break- 
ing down or drying up of pustules, especially if there be hemor- 
rhage, are darker, more tenacious and thicker, as in ecthyma. 
The crusts of syphilis are usually firmer and less friable in structure 
than those of eczema, and frequently have a heaped up, shell- 
like appearance; they sometimes have a dark greenish tint, 
and may be seated upon a superficial or deep ulcer. Sebaceous 

*See an interesting article by Saboureand on Scales and Crusts, Jour. Cut. 
Dis., 1903, p. 61. 



28 DISEASES OF THE SKIN. 

crusts, as those of seborrhoea, are yellowish or brownish and 
have a greasy feel and appearance. The crust of tinea favosa 
is composed chiefly of epithelial cells, debris and the fungus, the 
latter generally in profusion, and is of a more or less dingy, 
sulphur-yellow color and distinctly cup shaped. 

Scales. Scales are dry laminated masses of epidermis which 
have separated from the tissues beneath. 

Scales vary greatly in form, shape and size, according to the 
disease in which they occur, and their appearance in a given 
case will often determine the diagnosis. In some diseases scales 
are proliferated and thrown off in great quantity. In pityria- 
sis rubra and in active psoriasis handfuls may be gathered daily. 
Sometimes scales are formed in thick heaps as in psoriasis, some- 
times in thin branny flakes as in some forms of eczema, some- 
times in thin micaceous films as in pityriasis rubra. 

At times the scaly product of skin disease is found composed 
of a dried serous or puriform matter together with epithelium. 
Thus a mixture of scales and crusts is often found in eczema 
and other diseases. Scaling in the form of small or large lamel- 
lae, constituting sometimes a localized exfoliation of the epidermis 
designated exfoliative desquamation, is met with in impaired 
nutrition, as a result of nerve injury or operation. 

Excoriations. Excoriations are variously sized and shaped 
areas, characterized by loss of cutaneous tissue, confined usu- 
ally to the epidermis, generally the result of local injury. They 
comprise slight wounds, erosions, abrasions of the skin, lacera- 
tions and scratch marks. Scratching or rubbing on the part of 
the patient is the cause of the vast majority of excoriations. 
Excoriations occur most abundantly in eczema, scabies and 
pediculosis. They also occur in the so-called "neurotic excoria- 
tions" when they are automatically produced by the patient under 
the influence of obscure impulses connected with the hysterical 
state. Also in other conditions where the epidermis is defective. 

Fissures. Fissures are variously sized and shaped linear 
cutaneous cracks and wounds, due to disease in the skin or to 
external agencies, having their seat mainly in the epidermis. 



SECONDARY LESIONS. 20. 

They commonly occur in the natural furrows of the skin, as 
the palms, soles, fingers or toes, but may occur in other regions, 
as the natural apertures of the body, the nostrils, mouth, anus, 
etc. They appear as clefts in the skin and are due to a loss of 
elasticity and resisting power, the effect of disease. They fre- 
quently occur in eczema and are also met with in ichthyosis, 
syphilis and psoriasis or as a result of local irritants heat, cold, 
etc. They appear as clefts, dry or moist linear openings. 

Ulcers. Ulcers are irregularly sized and shaped losses of sub- 
stance or excavations of the cutaneous tissues, the result usually 
of some preceding disease. In some cases the alteration of the 
tissue is due to a simple inflammatory process, as in simple ulcer 
of the leg, in others it is due to a specific inflammation, as in lupus 
vulgaris, carcinoma, syphilis, lepra or other so-called neoplasmata. 

Ulcers vary as to size and shape. They may be no larger than 
a pin-head or as large as the hand or larger. Their outline is 
usually roundish but may be kidney shaped, as in syphilis, or 
irregular. They may be excavated or shallow, sharply defined, 
or shelving up irregularly to the surrounding skin. They 
usually show a purulent discharge. They do not remain con- 
stant but tend to change their form, either healing or growing 
larger. Ulcers when healed over leave a cicatrix or scar. 

Scars. Scars are new formations, consisting mainly of connec- 
tive tissue, occupying the place of former normal tissue, the result 
generally of injury or previous disease. 

Scars are not invariably the result of an injury or previous 
disease. In morphcea, scleroderma, atrophia cutis and the like, 
in keloid, lepra, etc., scars develop without previous perceptible 
disease. As a general thing, however, scars result from ulcers 
or injuries involving loss of substance. Scars are usually indolent 
but are sometimes painful. In some diseases, as keloid, they tend 
to hypertrophy. In hypertrophy of scars immediately following 
injury or disease, the prognosis is favorable as to the disappear- 
ance of the hypertrophy. In true keloid, however, spontaneous 
subsidence is extremely rare. Scars are permanent, continuing 
to exist through life with little if any alteration. 



30 DISEASES OF THE SKIN. 

CLASSIFICATION. 

In a text-book, that classification is best which enables the 
student to grasp the association of diseases so as to conceive of 
them in their relation to one another. Almost as important as 
this is the avoidance of any original and individual classification 
on the part of the author. Much of the "confusion of tongues," 
which has been attributed to dermatological writers, has arisen 
from the effort on the part of each writer to put forth such a 
classification and nomenclature as seemed most perfect, with but 
little regard to the arrangements of others. 

American dermatologists, especially of late years, have, how- 
ever, agreed upon a classification based upon that of Hebra and upon 
a nomenclature sanctioned by the American Dermatological As- 
sociation. In this way students all over the country are being 
taught on the same general scheme, and, awaiting the perfect 
system which shall be based upon an accurate knowledge of the 
pathological anatomy of skin diseases and of the processes con- 
cerned in their evolution, we can do no better, I think, than 
pursue the plan now so generally adopted. 

The classification employed in the present volume is as fol- 
lows: 

CLASS I. HYPEREMIAS. 

Erythema hyperaemicum 
Erythema intertrigo 
Erythema scarlatinoides 

CLASS II. INFLAMMATIONS. 

a. Having erythema as a prominent symptom with 

exudations of various kinds in addition. 
Erythema multiforme 
Erythema nodosum 
Erythema induratum 
Pellagra 

b. Characterized by oedema as a marked symptom. 

Urticaria 

Urticaria pigmentosa 

(Edema angioneuroticum 



CLASSIFICATION. 3 1 

c. Erythemato -squamous. 

Pityriasis rosea 
Dermatitis exfoliativa 
Dermatitis exfoliativa epidemica 
Dermatitis exfoliativa neonatorum 

d. Papular. 

Prurigo 
Lichen ruber 
Lichen scrofulosus 

e. Papulosquamous. 

Psoriasis 

f. Multiform (erythematous, papular, vesicular, etc.). 

Eczema 

Eczema seborrhceicum 

g. Vesicular and bullous. 

Herpes simplex 

Herpes zoster 

Hydroa vacciniforme 

Pompholyx 

Pemphigus 

Dermatitis herpetiformis 

Dermatitis repens 
h. Vesico -pustular and pustular. 

Impetigo 

Impetigo contagiosa 

Impetigo herpetiformis 

Ecthyma 
i. Phlegmonous. 

Furunculus 

Carbunculus 

Phlegmona diffusa 
j . Erytliemato-oedematous. 

Erysipelas 

Erysipeloid 
k. Pustular, papillomatous, necrotic and gangrenous. 

Dissection wounds 

Equinia 

Malignant pustule 

Sphaceloderma 

Dermatitis gangrenosa infantum 

Multiple gangrene in adults 



32 DISEASES OF THE SKIN. 

Diabetic gangrene 
Symmetric gangrene 

1. Varied — multiform, superficial or deep-seated. 
Dermatitis calorica 
Dermatitis traumatica 
Dermatitis venenata 
X-ray dermatitis 
Dermatitis factitia 
Dermatitis medicamentosa 

m. Exanthemata* 

(i) Erythematous maculo-papular 
Scarlatina 
Rubeola 
Rotheln 

(2) Vesicular 
Varicella 

(3) Primarily papular, then vesicular and 

pustular 
Variola 

(4) Erythematous, vesicular, pustular, multi- 

form, etc. 
Vaccinal eruptions. 

CLASS III. HEMORRHAGES. 

Purpura 

CLASS IV. HYPERTROPHIES. 

Lentigo 

Chloasma 

Naevus pigmentosus 

Acanthosis nigricans 

Clavus 

Callositas 

Keratosis palmaris et plantaris 

Keratosis senilis 

Keratosis pilaris 

Keratosis follicularis 

Verruca 

Cornu cutaneum 

Ichthyosis 

Porokeratosis 

* Excepting varicella and vaccinal eruptions the exanthemata have not been 
described in the present work. 



CLASSIFICATION. 33 



Angiokeratoma 
Scleroderma 
Sclerema neonatorum 
(Edema neonatorum 
Elephantiasis 
Dermatolysis 

CLASS V. ATROPHIES. 

Albinismus 

Vitiligo 

Glossy skin 

Atrophia senilis 

Striae et maculae atrophicae 

Diffuse idiopathic atrophy 

Kraurosis vulvae 

Ainhum 

Perforating ulcer of the foot 

Morvan's disease 

CLASS VI. NEW GROWTHS. 

a. Benign. 

Cicatrix 

Keloid 

Dermatitis papillaris capillitii 

Molluscum contagiosum 

Multiple benign cystic epithelioma 

Adenoma sebaceum 

Lymphangioma circumscriptum 

Xanthoma 

Xanthoma diabeticorum 

Colloid degeneration of the skin 

Angioma 

Naevus vascularis 

Telangiectasis 
Angioma serpiginosum 
Fibroma 
Lipoma 
Myoma 
Neuroma 
Of possible malignancy. 
Rhinoscleroma 
Tuberculosis cutis 

Tuberculosis ulcerosa 



34 DISEASES OF THE SKIN 

Tuberculosis disseminata 

Tuberculosis verrucosa 

Scrofuloderma 

Lupus vulgaris 
Lupus erythematosus 
Syphilis 
Aleppo boil 
Framboesia 
Verruga 

Malignant. 

Carcinoma 

Paget's disease 

Epithelioma 
Xeroderma pigmentosum 
Sarcoma 

Granuloma fungoides 
Leprosy 

CLASS VII. NEUROSES. 

Hyperesthesia 

Dermatalgia 

Erythromelalgia 

Pruritus 

Anaesthesia 

CLASS VIII. DISEASES OF THE APPENDAGES. 

(i) Nails. 

Onychauxis 
Atrophia unguium 
Onychomycosis 

(2) Hair; hair follicles. 
Hypertrichosis 
Atrophia pilorum propria 

Fragilitas crinium 

Trichorrhexis nodosa 

Monilethrix 
Piedra 

Tinea nodosa 
Lepothrix 



CLASSIFICATION. 35 

Canities 

Alopecia 

Alopecia areata 

Folliculitis decalvans 

Sycosis 

Conglomerate suppurative folliculitis. 

(3) Sebaceous glands. 

Seborrhcea 

Milium 

Steatoma 

Comedo 

Acne 

Acne varioliformis 

Acne rosacea 

(4) Sweat glands. 

Anidrosis 

Hyperidrosis 

Bromidrosis 

Chromidrosis 

Hasmatidrosis 

Uridrosis 

Phosphoridrosis 

Sudamen 

Hydrocystoma 

"Miliaria 

Hydradenitis suppurativa 

CLASS IX. PARASITIC AFFECTIONS. 

a. Vegetable. 
Favus 
Ring-worm 
Tinea imbricata 
Tinea versicolor 
Erythrasma 
Pinta disease 
Myringomycosis 
Actinomycosis 
Mycetoma 
Blastomycetic dermatitis 



36 DISEASES OF THE SKIN. 

b. Animal. 

Living on or attacking the skin — 
Pediculosis — capitis, corporis, pubis 
Cimex lectularius 
Pulex irritans 

f Ixodes 

I Dermanyssus avium 
Miscellaneous -\ Culicidae 
I Similidae 
L Apidae, etc 
Penetrating the skin (either parasites or 
larvae) — 
Scabies 

Leptus autumnalis 
Pulex penetrans 
Dracun cuius 
Cysticercus cellulosae 
Demodex folliculorum 
(Estridae 
Craw craw 
Echinococcus, etc. 



HYPEREMIAS. 37 



CLASS I. HYPEREMIAS. 

The hyperemias properly include only those cutaneous con- 
ditions characterized by an abnormal flux of blood, unattended 
by ordinary inflammatory changes. It is difficult to draw the 
line between hyperaemia and inflammation, for there is often a 
slight tendency to inflammatory action even in the most typical 
erythemata. For convenience sake, however, the distinction 
must be attempted. Hyperaemia is usually active but it may 
be passive, a stasis or lividity of the surface going on to cyanosis. 
The active hyperaemias are represented by the non-inflammatory 
or non-exudative erythemata. 

ERYTHEMA. 

Erythema hypercemicum, or erythema simplex is characterized 
by redness, occurring in the form of variously sized, diffused 
or circumscribed, non-elevated patches, irrespective of cause. 
There are two varieties; the idiopathic, under which head are 
included the erythemata occasioned by heat and cold, continued 
pressure or rubbing, and the action of irritant or poisonous sub- 
stances, as mustard, arnica, various dye-stuffs, acids and alkalies; 
and the symptomatic, due to some general derangement of the 
economy, as disorders of the stomach and bowels, etc., or con- 
nected with toxic infection. Such are the roseola of infants and 
young children and the erythema injectiosum of Esherich and 
Shaw.* 

The diagnosis of the idiopathic erythemata is usually made 
without difficulty. In the symptomatic erythemata consider- 
able difficulty is sometimes met with, especially when there is 
any febrile or general disturbance. The symptoms of the 
various exanthemata, measles, scarlet fever, etc., may be excluded 

* Shaw. Am. Jour. Med. Sci., Jan., 1905. 



38 DISEASES OF THE SKIN. 

to begin with, but considerable difficulty is often encountered in 
making an off-hand diagnosis.* 

Certain general diseases are at times accompanied by hyper- 
emia of the skin, which shows itself in the form of roundish spots, 
the size of a pea or finger nail, to which the name roseola has 
sometimes been given. It denotes simply the form of erythema, 
and in no way indicates the nature of the disease which has 
brought it forth. 

The treatment of erythema simplex must obviously depend 
upon its cause in any given case. The removal of the obvious 
cause is alone usually sufficient in idiopathic erythema, but in 
the symptomatic form of the disease the internal disorder to 
which the cutaneous manifestation is due must be diligently 
sought out and treated, with a view to removal. Locally, sooth- 
ing and astringent lotions may be employed. A much-used lotion 
in erythema, when the skin is unbroken, is the following: 

J\. Acidi hydrocyanici, dil., 5ij ( 8. ) 

Bismuthi subnitrat, 5 i j— iv ( 8-16) 

Aquae aurantii nor., . . . . . q.s. ad Oss (240. ) 

Sig. — Outside use. 

Dilute lead water, or lead water and laudanum, or simple 
alcohol and water, may be used with satisfaction in most cases. 
As for powders, though useful, they will be found in practice 
difficult to keep in contact with the skin. Ointments are very 
apt to disagree in simple erythema, and should, therefore, as 
a general thing, be eschewed. 

ERYTHEMA INTERTRIGO. 

Erythema intertrigo is characterized by redness, heat and an 
abraded surface, with maceration of the epidermis. It occurs 
chiefly in those parts where the natural folds of the skin come in 
contact with one another, as about the nates, perineum, groins, 
axillae, and beneath the mammae, and is produced by the fric- 
tion of two opposing surfaces. It is especially common among 

*See Wingfield. Erythematous rashes simulating the acute exanthemata. 
Brooklyn Med. Jour., 1902, p. 349. 



ERYTHEMA INTERTRIGO. 39 

fat persons, women with pendulous mammae, and infants whose 
skin is tender. The skin feels chafed and becomes hot and 
sore. Perspiration also, at times, macerates the epidermis, 
and gives rise to the secretion of an acrid, mucoid fluid. If 
neglected, a true dermatitis may set in. The affection comes 
suddenly, and if taken in time may usually be quickly checked, 
but if not treated it soon becomes very annoying. Occurring 
between the nates, a common seat of the disease, it may interfere 
with walking. It is usually harder to cure in infants, where the 
diaper, saturated with more or less acrid secretions, is constantly 
in contact with the skin. 

The disease is one of summer rather than winter, although 
it may occur at any time of the year, if sufficient cause be present. 
It is sometimes brought on by wearing rough underclothing. I 
have known severe erythema intertrigo of the nates and thighs 
caused by walking about, after sea-bathing, in wet bathing- 
clothes. The rough surface of the flannel, as it dries, becomes 
coated with minute acicular crystals of salt, which cut like tiny 
knives. The patient sometimes supposes himself to have been 
" poisoned" by a hired bathing dress, when the cause of his 
erythema is purely mechanical, as just mentioned. 

The disorder is to be distinguished from eczema, and in the 
case of infants from the erythema of hereditary syphilis. As 
erythema intertrigo often runs into eczema, the difference often 
is only one of degree; eczema is more infiltrated and apt to weep, 
while characteristic papules or vesicles are seen around the border. 
Syphilitic erythema is apt to be of a more dusky shade, slightly 
infiltrated and not entirely disappearing under pressure, but 
leaving a yellowish color. Moreover, thicker papular or tuber- 
cular lesions are seen about the anus in many cases and the 
characteristic nasal-catarrhal troubles are usually present. 

The treatment of erythema intertrigo is commonly an easy 
matter. 

As a rule, very little is required beyond cleanliness and atten- 
tion. The parts should be washed with cold water alone, or with the 
sparing addition of a superfatted soap, and dried with a soft rag or 



4-0 DISEASES OF THE SKIN. 

towel. The folds of the skin are to be separated and kept apart 
by pieces of soft linen, lint, or absorbent cotton. Dusting powders 
are the most convenient remedies is most mild cases. When 
there is little discharge, or none, starch or lycopodium may be 
used. Starch, however, is apt to cake and sour if dusted on a 
moist surface. The following powders are much less liable to 
this objection, and may be used alone or in combination: Oleate, 
stearate, oxide and carbonate of zinc, carbonate and subnitrate 
of bismuth, magnesia, fullers' earth, kaolin, and talc. When 
starch is admissible, and there is no break in the skin, the fol- 
lowing preparation is one of the best: 

1$. Pulv. camphorae, 3 j (4 ) 

Pulv. zinci oxidi, 

Pulv. amyli, aa . . . . § j (32) M 

To be made into a perfectly impalpable powder.* 

The mixture should be kept in a tightly-corked, wide-mouthed 
bottle. 

In cases which are obstinate, diluted black wash, applied 
several times a day, alone or followed by the use of some bland 
powder, as above, is an efficacious remedy. Dilute alcoholic 
lotions, composed of alum or sulphate of zinc, a few grains to 
the ounce, also prove serviceable in stubborn cases. In inter- 
trigo about the thighs and genitalia there is often an element of 
hyperidrosis. In these cases tincture of belladonna maybe painted 
on the parts daily and followed by one of the more astringent 
powders, as the oxide of zinc. In the case of infants, when the 
intertrigo is about the anus, and the stools are thin, with an acid 
smell, the following powder may be given internally: 

I£. Calcis praecipitat gr. iss (0.096) 

Bismuthi subnitrat., gr. ij (o. 13 ) 

Sacch. alb., gr. iij (0.20 ) M. 

Sig. — One, thrice daily. 

ERYTHEMA SCARLATINOIDES. 

Erythema scarlatinoides, or scarlatinijorme " scarlet rash" 
is the term applied to certain erythemata which are followed 

*This is commonly known as "McCall Anderson's Powd— 



ler. 



ERYTHEMA SCARLATINOIDES. 41 

by more or less desquamation. There is an acute and a sub- 
acute type. In the acute form, fever and slight constitutional 
disturbance may precede the eruption, or it may appear suddenly 
without premonitory symptoms. It may appear first at any 
point, though the face and head are apt to be spared, and it may 
cover a part or the whole surface. The rash spreads rapidly 
and in a few hours or days reaches its full development with a 
punctate macular or diffuse appearance and a color which may 
be any shade of red, usually scarlet, but sometimes dull and 
livid. The mucous membrane of the tongue and fauces may 
be reddened and denuded of epithleium. Desquamation begins 
three or four days after the onset of the disease. It may be fur- 
furaceous or the epidermis may come off in sheets, the epidermis 
of the hand, for instance, being shed complete like a glove. Only 
in exceptional cases are the nails and hair shed. Complete 
involution requires from a few days to several weeks. 

The subacute forms of scarlatiniform erythema show less 
constitutional disturbance, the rash has a greater tendency 
to be universal and, together with the desquamation, may per- 
sist for weeks and months, recurrences being frequent. Some 
cases are with difficulty distinguished from exfoliative derma- 
titis, and, in fact, both the acute and subacute types of erythema 
scarlatinoides at times tend to develop into the more severe 
affection.* 

The most common predisposing cause of erythema scarlatin- 
oides is idiosyncrasy. The exciting cause in most cases is a 
toxaemia of some kind. Infectious diseases, septicaemic condi- 
tions, peritonitis, rheumatism, gonorrhoea, abscess, empyema, 
uraemia, tuberculin or anti-diphtheritic injections, sewer gas pois- 
oning, certain articles of food and many drugs, may each at 
times, give rise to the eruption. 

The diagnosis is at times difficult, especially in the first days 
of the disease. It is most apt to be mistaken for scarlatina. 
The constitutional symptoms, however, are not so intense, the 

*Stelwagon and Hyde and Montgomery refer to reported cases of "skin shed- 
ding," " deciduous skin," etc., as coming under this head. 



42 DISEASES OF THE SKIN. 

rash appears more rapidly and on any part of the body. It is 
not so apt to be universal, desquamation begins early and is exten- 
sive. The fauces, though red, are not swollen. There is absence 
of the strawberry tongue and all history of contagion. From 
measles the disease we are discussing differs in not presenting the 
well known concomitant symptoms and in not beginning on the 
face. From rotheln by the absence of the characteristic gland- 
ular enlargements. 

The treatment of erythema scarlatinoides consists in removing 
the cause when this can be ascertained. Purgatives, followed 
by intestinal disinfectants are appropriate in many cases, and 
careful diet with the addition of tonics and digestive agents may 
afterwards be employed. Externally, the local applications 
mentioned under erythema simplex may be directed. 

While the prognosis is generally favorable, frequent recurrences 
occur in rare cases and the disease has been known to develop into 
exfoliative dermatitis (g.v.). 



ERYTHEMA MULTIFORME. 43 



CLASS II. INFLAMMATIONS. 
ERYTHEMA MULTIFORME. 

Erythema multiforme is an inflammatory disease character- 
ized by the occurrence of dusky red macules, papules or tu- 
bercles occurring discretely or in patches of various size and 
shape. 

The name has been given to this form of erythema, on account 
of the protean character of the lesions, which manifest them- 
selves as erythematous patches of the most varied shapes and 
sizes, or as papules, vesico-papules, and tubercles, scattered 
or in groups. Various names are given, denoting the arrange- 
ment of the lesions. Thus we have E. annulare, occurring in 
circular patches. Sometimes the circles are very large, or are 
broken, and assume gyrate forms; this is E. marginatum. 

Erythema papulation is the commonest variety. It shows 
itself in the form of isolated or aggregated flat papules of varied 
size and shape, bright red, bluish or purplish in color, and which 
soon fade, seldom lasting longer than a week or ten days. E. 
tuberculatum is simply an exaggeration of this form, and all 
of the varieties mentioned are but forms and stages of the same 
process, and are often met with, two or more occurring together 
simultaneously on the same individual. The lesions of E. 
multiforme disappear spontaneously, leaving, perhaps, slight 
pigmentation and desquamation. 

Erythema iris, sometimes called "herpes iris" and (one form) 
"hydroa," is characterized by the appearance of one or more 
groups of variously sized vesico-papules or vesicles, arranged in 
the form of concentric rings, attended, as a rule, by the display 
of various colors. The patches vary in size from that of a small 
coin to several inches in diameter, and are made up of a number 
of, usually rather indistinct, vesico-papules or vesicles which 



44 



DISEASES OF THE SKIN. 



arrange themselves side by side, so as to form a perfect ring. 
It is a peculiarity of the disease that new vesicles are constantly 
forming on the periphery while the centre is healing up. When 
there are a number of independent patches they sometimes coal- 
esce, and the interlaced arrangement of the concentric and varie- 
gated circles present a picture so striking that, once seen, it can 
never be forgotten. It looks, sometimes, as if the patient had 
been tattooed in rings of various colors, the prevailing tints being 
red, yellow, and brown. The backs of the hands and feet, as 
in the other varieties of E. multiforme, and the arms and legs are 




Fig. 4. — Erythema multiforme. (Courtesy of Dr. Duhring.) 

the localities usually attacked, but sometimes the trunk is also 
involved. The eruption is not usually accompanied by sub- 
jective sensations of any kind. 

Erythema multiforme is usually found on the backs of the 
hands and the fingers, forearms and legs. It may show itself 
on the face and trunk. Sometimes it attacks the mucous mem- 
brane of the mouth, anus, etc., and even the conjunctiva. Now 
and then it is general, involving the whole surface. A marked 
feature of the disease is the disproportion between its appear- 
ance and the subjective symptoms' to which it gives rise. Not- 



ERYTHEMA MULTIFORME. 45 

withstanding the angry look which the eruption often assumes, 
there is very little itching or burning. Sometimes constitutional 
symptoms, as malaise, headache, rheumatic pains, and gastric 
derangement, are present in marked cases. The temperature is 
rarely elevated through considerable febrile disturbance has been 
noted in a few T cases. 

The affection is much commoner in the spring and fall, al- 
though it sometimes occurs at other periods of the year. It 
is among the eruptions of the skin more frequently met with in 
this country. The American statistics show 915 cases of ery- 
thema multiforme among 123,746 cases of skin diseases reported. 

The etiology of the disease is somewhat varied. In general, 
the cause may be said to be either nervous, toxic, or infectious. 
It may occur as the result of moral shock, of menstrual disturb- 
ance, or irritation of the genito-urinary canal, or in the course 
of chorea, hysteria, myelitis or other disturbances of the central 
nervous system. Among toxic influences the ingestion of cer- 
tain drugs, nephritis or uraemia and, especially, intestinal auto- 
intoxication may be mentioned. Almost all known infections 
may be accompanied by attacks of erythema multiforme, as 
cholera, tuberculosis, syphilis, typhoid, fever septicaemia, etc. 
Osier has developed the complications of erythema in a series 
of valuable articles.* 

Erythema multiforme is a mildly inflammatory affection some- 
what similar to urticaria. It is, in all probability at first, at least, 
a toxic angioneurosis. The association with rheumatism has led 
many to believe that it is due to the same underlying cause. 
Dilatation of the blood-vessels with cell proliferation around 
their walls, cell emigration and oedema of the cutis, with some- 
times extravasation of red blood corpuscles and colored serum 
characterize the anatomical processes. 

Erythema multiforme is to be distinguished from urticaria 
by the absence of burning and itching and the slower and more 
regular development of the lesions. In urticaria the lesion is a 

* Am. Jour. Med. ScL, 1895, p. 629. lb., 1904, p. 1, and Brit. Jour. Derm., 
1900, p. 227. Chronic Purpuric Erythema, Jour. Cut. Dis., 1903, p. 297. See also 
Schamberg, An Inquiry into the Nature of the Toxic Erythemata., lb., 1904, p. 461. 



46 DISEASES OF THE SKIN. 

transient wheal and new lesions may often be developed by 
drawing a hard object across the skin. The individual lesions 
tend to be evanescent. They are whitish in color with a light 
rose tint. The color of the erythema multiforme lesions is highly 
characteristic. They are a raspberry red, sometimes showing a 
slight bluish-purple reflection. Transition eruptions are not rare 
and an error in diagnosis is not serious. 

From papular eczema, erythema multiforme is distinguished 
by the variety of its lesions, mostly of large size, the absence 
of burning or itching, the fact that it runs a regular course. In 
papular eczema the lesions are small, regular in shape and out- 
line and accompanied by burning and, particularly, by itching 
with the display of scratch marks, etc. 

In eczema erythematosum there is less definition of each patch 
and the redness is commonly diffuse and has not the raspberry 
tint of erythema multiforme. Rotheln is to be distinguished 
by its adenopathy, its pharyngeal symptoms and its flattish spots. 

Other affections with which erythema multiforme is apt to be 
confounded are, purpura rheumatica, erythema nodosum, der- 
matitis herpetiformis, lichen planus, and, when bullar, or taking 
the form of "hydroa," with pemphigus. A reference to the de- 
scription of these diseases under their respective heads will give 
the data for distinguishing them from erythema multiforme. 

Copaibic eruptions sometimes simulate erythema multiforme. 

In the majority of cases of erythema multiforme no active 
treatment is called for; salicylate of sodium or strontium, how- 
ever, has been used with success in some cases. Light diet, 
the avoidance of stimulating drinks, mild saline laxatives, with 
the local application of dilute alcohol or of carbolic acid, may be 
employed, as this: 

1$. Acidi carbolici, gr. x ( 0.60) 

Glycerinae, f3j ( 2. ) 

Aquae, foj (32. ) M. 

Dusting powders, as that of camphor, oxide of zinc, and starch, 
given under erythema intertrigo also prove useful at times. 



ERYTHEMA NODOSUM. 47 

ERYTHEMA NODOSUM. 

Erythema nodosum is an inflammatory affection, of an acute 
type, characterized by the formation of rounded or ovalish, vari- 
ously-shaped, more or less elevated, reddish nodes. The disease 
is apt to be ushered in by some general disturbance of the system, 
febrile disturbance, gastric uneasiness, malaise and, not infre- 
quently, with rheumatic pains and swellings about the joints. 
The nodes often appear suddenly ; they may come on any part of 
the body, but are commonly found on the legs and arms. They 
vary in size from a small nut to an egg, are reddish in color, tend- 
ing to become bluish or purplish. As they disappear, they under- 
go various changes of color, like a bruise, and it is often difficult to 
distinguish the lesions from ordinary contusions, especially when 
they occur over the shins. When the disease is at its height, the 
lesions have a tense, shining look, as if they contained fluid, and 
often an indistinct sense of fluctuation is perceptible. They 
never suppurate, however. Not unfrequently they are more or 
less hemorrhagic in character. They vary in number from a few 
to a dozen or more. They come out, as a rule, in crops. They 
are painful or tender on pressure, and are usually attended by 
burning sensations. Sometimes the lymphatic vessels are in- 
volved. The affection usually terminates in recovery in two to 
four weeks though the duration varies between wide limits. 

The constitutional symptoms usually abate in average cases 
after the first few days. Sometimes, however, the fever continues. 
Occasionally there is visceral involvement. 

The disease occurs chiefly among those under the age of thirty. 
It is more apt to occur among the weak and anaemic. Erythema 
nodosum is a rather uncommon disease. 

The nature of the disease is not clear, although the febrile reac- 
tion and visceral involvement point towards a specific infection. 
It is closely related to erythema multiforme and, in fact, is believed 
by many observers to be a manifestation of this disease. I can- 
not at present share this view. 

The anatomy of the lesions shows, dilatation of blood-vessels 



48 DISEASES OF THE SKIN. 

and closely crowded cells in the papillary layer and corium and, 
in some instances, extravasation of blood or transudation of 
blood coloring matter. The leukocytes are sometimes so massed 
in the veins that they have the aspect of white thrombi. Phlebitis 
of the larger subcutaneous veins has been met with. There is 
marked serous infiltration of the cutaneous and usually subcu- 
taneous tissues. The epidermis is rarely involved. 

Erythema nodosum is liable to be confounded with bruises, 
abscesses, gummata, and the lesions of erythema induratum. 
The former, however, only occur one, two or three in number as 
a usual thing, and they may go on to suppuration which never 
occurs in erythema nodosum. Rheumatism also is a frequent 
concomitant of the latter disease. The lesions of erythema indura- 
tum are dark in color from the beginning, slower in their course, 
soon break down and ulcerate, are unaccompanied by febrile 
and rheumatic symptoms and usually occur in subjects with 
tuberculous tendencies. 

Erythema nodosum usually runs its course in a few weeks 
and ends favorably. A few fatal cases have been reported, but 
in these, septic infection, with the skin disease as a symptom or 
accessory, may be supposed to have existed. 

The treatment is largely symptomatic and expectant. Rest, 
preferably in bed, a plain diet with a saline laxative is usually 
all that is required. Later intestinal antisepsis, quinine and the 
salicylates may be employed if thought desirable. Locally 
lead- water and laudanum, followed by 5 to 10 per cent, ichthyol 
ointment, may be applied as there may be some tenderness and 
pain in the lesions. Rheumatic pains in the joints require the 
usual wrapping in cotton, etc. 

ERYTHEMA INDURATUM. 

Erythema induratum is a sluggish, chronic, skin affection usually 
found upon the legs, and characterized by the more or less con- 
tinuous formation of a succession of nodules which, at first small, 
enlarge to variable size, become purplish in color and terminate 
after a long period in necrosis. 



ERYTHEMA INDURATUM. 49 

The lesions usually occur on the sides of the lower calf region, 
the legs and occasionally the thighs. They are at first invisible, 
but can be felt on palpation as deep-seated, indurated, pea-sized 
nodules. In the course of days or weeks they enlarge to the size 
of a cherry or walnut, the skin over the lesions becoming purple 
or red and later violaceous. The lesions become softer and 
gradually disappear by absorption, or they atrophy or undergo 
necrosis and result in a punched-out, somewhat pleep, sluggish- 
looking, irregular ulcer. 

The disease occurs almost exclusively in girls and women 
between the ages of twelve and thirty, especially those who are 
obliged to stand much upon their feet. The nature of the 
affection is obscure, although most observers consider it tu- 
berculous in origin. 

Erythema induratum is to be distinguished from syphilitic gum- 
mata and from erythema nodosum. The syphilitic lesions usually 
run their course more rapidly, suppurate more freely, and are 
markedly purulent; in erythema induratum the destruction is 
rather from necrosis than suppuration. The lesions are more 
painful and inflammatory in syphilitic gummata, they are fewer 
in number and do not often occur on both legs. The syphilitic 
lesions are markedly improved by appropriate treatment, while 
anti-syphilitic treatment never helps but often aggravates the 
lesions in erythema induratum. 

Erythema nodosum is more acute in its course, some lesions 
remain small and pink, the larger nodes are painful and tender 
and the lesions never suppurate. Moreover, erythema nodosum 
usually occurs on the anterior tibial surface of the leg, though 
it may occur on any part of the body, while erythema indura- 
tum is confined, for the most part, to the sides and back of the 
calf. 

Erythema induratum is an obstinate and persistent disease, 
but under appropriate treatment the prognosis is favorable. 
Cod-liver oil, iron, quinine and strychnine with nutritious food 
are called for. Rest, with the leg in a support, and bandaging 



SO DISEASES OF THE SKIN. 

should be employed. Locally antiseptics, as boric acid, europhen, 
etc., may be applied.* 

PELLAGRA. 

Pellagra is an endemic disease of the skin, characterized by 
the appearance of chronic inflammatory patches of an erythem- 
atous or erythemato-squamous character, accompanied by burn- 
ing and itching and frequently leading to debility, digestive dis- 
turbances and symptoms indicating involvement of the cerebro- 
spinal system. 

The disease occurs chiefly in Italy, Roumania and Eastern 
Europe; it is practically unknown in this country. Sherwell 
has reported one instance occurring in New York in an Italian 
sailor. Alcoholic excess, poverty, poor hygienic surroundings, 
and exposure to the sun are predisposing factors, particularly 
the latter. It was formerly supposed to be due to the ingestion 
of spoiled maize, containing the bacterium Maidis, but this 
view is not now generally held. Post-mortem examinations show 
pachymeningitis, sclerosis of the brain and cord, anaemic and 
atrophic conditions of the internal organs, with fatty degenera- 
tion and pigmentary changes. 

The diagnosis depends upon the occurrence of the disease in 
the geographical localities mentioned, while the seat of the lesions 
on the back of the hands, the lower forearms, face, and often 
dorsal surface of the feet is characteristic. Dermatitis of a 
mild type, with occasional vesiculation and bullous lesions, with, 
later, pigmentation, and accompanied by disturbance of diges- 
tion, diarrhoea, nervous involvement, melancholy, etc., are also 
characteristic. 

In slight attacks the prognosis is favorable; when the symp- 
toms are severe the outlook is unpromising. The duration, 
however, of fatal cases is long; fifteen to twenty years in some 
instances. 

*See Colcott Fox, Westminster Hosp. Reports, 1888, p. 144; and Brit. Jour. 
Derm., 1893, pp. 225 and 293; also Ibid, 1896, p. 178; also J. C. White, Jour. 
Cut. Dis., 1894, p. 471;' Dade, Ibid. 1899, p. 306; Johnson, Ibid, p. 312; and 
others. The literature is somewhat voluminous. 



URTICARIA. 51 

The treatment consists in placing the patient under the best 
possible hygienic circumstances, and careful nourishment, with 
the usual tonics. 

URTICARIA. 

Urticaria is an inflammatory disease of the skin, character- 
ized by the development of wheals of a whitish or reddish color, 
accompanied by sticking, pricking, tingling sensations. The 
lesions are apt to come out suddenly and disappear again in a 
very short time, so that a patient seeking advice is often unable 
to show a sign of the disease, excepting scratch marks, even at 
repeated visits to the physician, when he may have been tortured 
and disfigured by it between times. The wheals are of various 
sizes, sometimes as small as a split pea, sometimes as large as the 
palm of the hand. They average finger-nail size. While the 
smaller lesions are usually round, the larger ones may be very 
irregular, crescentic, or linear; often they assume a grotesque 
outline. They may be barely elevated above the skin, or may 
rise to an eighth of an inch in height. They may be soft or firm 
to the touch, and whitish or pinkish in color. On the face the 
urticaria rash may cause great temporary deformity. The 
lip, or half the lip, for instance, may within a few minutes swell 
out to a great size, and remain thus for an hour or more. The 
eruption burns, stings, and tingles, as if the skin had been stung 
by nettles, hence the popular English name of the disease, ''net- 
tle rash", while in this country it is popularly called ''hives/' 
Sometimes these sensations of burning and tingling are merely 
annoying; at other times they may prove distressing to the last 
degree. Rubbing and scratching commonly aggravate the dis- 
ease, bringing out new wheals. 

The lesions of urticaria frequently change their locality, the 
eruption appearing now in one part of the body, and again in 
another. It occurs at all ages and in both sexes. Its duration 
depends entirely upon the presence or removal of the exciting 
cause. There are several varieties of urticaria: 1. Urticaria 
papulosa, described above. One form occurs among children, in 



52 DISEASES OF THE SKIN. 

widely dispersed, pin-head to split-pea-sized, flat, or acuminate 
papules, which appear suddenly and last for hours or days. It 
is attended by severe itching.* 2. Urticaria hcemorrhagica, 
which is, in fact, urticaria occurring in the seat of a purpuric 
eruption, and is sometimes called "purpura urticans." 3. Urti- 
caria bullosa, where the wheals are transformed into blebs, which 
may assume some of the characteristics of pemphigus (see Ery- 
thema multijorme). 4. Urticaria tuberosa, or "giant urticaria," 
occurring in the form of large walnut- or even egg-sized, firm, 
more or less persistent nodes or tumors, resembling somewhat 
exaggerated tumors of erythema nodosum. 

Urticaria may be acute or chronic. The acute variety is 
usually, though not invariably, ushered in by slight febrile symp- 
toms, languor, headache, depression, gastric disturbance, furred 
tongue, etc. The rash appears suddenly, and may involve the 
whole body, or a portion only, accompanied by intense, and al- 
most intolerable, burning and stinging sensations. In a variable 
time, from one hour to a day, the symptoms subside and the 
eruption disappears, without leaving a trace, except in the form 
of scratch marks. Chronic urticaria may continue for months 
and years, or, indeed, as long as the cause exists. The individ- 
ual lesions, which are usually small, come and go as in the acute 
form; crop after crop may appear, the skin being hardly ever 
free from them. The patient's general health may appear 
fair. 

The causes of urticaria are numerous and of a very diverse 
character. Certain external irritants and poisons to the skin, 
as the stinging-nettle, jelly-fish, caterpillars, fleas, bed-bugs, and 
mosquitoes, are not infrequent causes. Among internal causes, 
gastric and intestinal derangements are by far the most common. 
An overloaded stomach, excess in wine, beer, or highly-seasoned 
food, may occasion an attack, while certain articles of food, 

* One form of urticaria very commonly met with among children is the affection 
known as lichen urticatus. It is characterized by the appearance of a pin-head-sized 
vesicle surrounded by a well-defined erythematous areola. The areola fades away 
after a day or two and the vesicle runs the usual course of such lesions. The 
eruption may develop into urticaria or the typical lichen urticatus lesions may be 
interspersed in the same subject with typical urticaria lesions. 



URTICARIA. 53 

as fish, oysters, clams, crabs, lobsters, pork, especially sausage, 
oatmeal, mushrooms, raspberries, and strawberries are all apt 
to bring out the eruption. The opening of a hydatid cyst has 
been known to give rise to urticaria. Various drugs have the 
same affect (see Dermatitis medicamentosa) in some individuals. 
In most cases of urticaria from these causes a certain idiosyncrasy 
seems to exist. Any irritation of the bowel, as by worms in 
children, may bring out the eruption. Sudden emotion or mental 
excitement in certain persons may also produce it. In females 
menstrual and uterine difficulties may cause urticaria. The 
disease is intimately connected with the nervous system, and 
patients who suffer from chronic urticaria are apt to be persons 
of more or less depraved nervous organization. 

The pathology of urticaria is similar to that of erythema multi- 
forme. The disease is an angioneurosis, the lesions being due to 
vaso-motor disturbance commonly of toxaemic character. In urtic- 
arial lesions dilatation, following spasm of the vessels results in 
effusion and, in consequence the overfilled vessels of the central 
portion are emptied by pressure of the exudation, and the pink or 
reddish color gives place to central paleness, while the pressed 
back blood accentuates the bright red tint of the periphery. 

The anatomy of the wheal shows it to be a firm elevation of a 
diffused semi-fluid material especially collected in the upper layers 
of the skin. The epidermis is unaltered but the whole corium is 
the seat of inflammatory changes. The blood-vessels and lymph- 
atics are enlarged and the corium swollen with serous exudation. 

The diagnosis of urticaria does not often present any difficulty, 
because the lesions are so peculiar in appearance, and because 
of the peculiar burning and tingling sensations. The small 
lesions, as found in children, may be mistaken for eczema, but 
a few scratches with the finger nail on the skin of any part of 
the body will arouse urticarial red or white bands and streaks, 
which show an irritable condition of the skin and are very char- 
acteristic. 

The treatment of urticaria depends greatly, for its success, 
upon the discovery and removal of the cause. When this is sus- 



54 DISEASES OF THE SKIN. 

pected to be some gastric disturbance, the precise articles of 
food of which the patient has been partaking should be inquired 
into; their quality, as to freshness, etc., should also be a matter 
of scrutiny. The possibility of the patient having eaten any- 
ting unusual should also be considered, as well as the previous 
ingestion of medicine. An emetic may be given in acute cases, 
if the contents of the stomach have been recently ingested and 
are suspected of being the cause. The bowels should be freely 
opened, if required by a saline purgative. The diet should be 
of the most simple and unstimulating character, and the subse- 
quent internal treatment should be directed against the digestive 
difficulty. The treatment in any given case must depend upon 
the result of a careful investigation into its nature and cause. 

Among medicines, the laxative mineral waters are often ad- 
vantageous : Hunyadi Janos, Arpenta — the alkaline waters, as 
Celestine Vichy or Saratoga Vichy, or sulphur waters, as the 
Richfield Springs water, with baths taken at the springs, may 
also at times be used with advantage. Diuretics are often of 
use. Quinia is often of value, whether malaria be present or 
not. Antipyrine in 20-grain to 30-grain (1.30-2.) doses at bed- 
time is sometimes useful. Arsenic is sometimes of service when 
other remedies fail. Iron also is useful. "Mistura ferri acida" 
(the formula of which is given under eczema), is a very useful 
remedy in many cases of urticaria. 

Bromide of potassium, chloral, and other sedatives may be 
required to give rest and calm to the nervous system, often injured 
by long- continued suffering. The preparations of opium should 
generally be avoided, but codein, gr. J (0.016) four times a day, 
I have sometimes found to give relief. Belladonna is a valuable 
remedy. It may be given either in the form of sulphate of atropia 
in doses of T -^o to -^ grain, (0.00054-0.001 1) morning and evening, 
or in the following combination : 

]$. Ext. belladonnae, gr. fo—fa (o. 001 1-0.0022) 

Ergotin, 

Quininae muriatj aa. . .gr. i (0.065) 

M. Fiat in pil. No. 1. 



URTICARIA. 5 5 

Two of these pills may be given every two hours until relief is 
obtained or until the dryness of the mouth becomes unsupport- 
able. Sulphurous acid, in drachm doses, diluted with simple 
syrup; salicylic acid, in 20-grain doses, thrice daily, and chloride 
of ammonium, in 10 to 20-grain doses, thrice daily, may at 
times be found useful. 

Intestinal antiseptics are very often required, especially in 
more chronic cases. The following formula may be recom- 
mended : 

fy Menthollis, gr. j (0.016) 

Guaiacol carb., gr. ij (0.13 ) 

Podophyllin, gr £ (0.008) 

Hydrarg. chlor. mite gr. £ (0.05 ) 

M. Fiat in capsulam j. — One of these one to three times a day. 

External treatment is of importance to calm the burning and 
tingling pain of the eruption, which is at times almost unendur- 
able. Alkaline baths, followed by soothing powders, such as 
are described under the treatment of acute eczema, will be of 
use. Sponging with vinegar and water, or alcohol, alone or 
diluted, often gives relief; it should be practiced frequently. 
One of the most useful applications in my experience is the 
following: 

1$. Menthollis, gr. j ( o 065) 

Acid carbolic, gr. v ( 0.3 ) 

Glycerin, f 3 j (4- ) 

Alcoholis, ad . . .f§j (32. ) 

M. 

Chloroform, a drachm (4.) to the ounce (32.) of alcohol, or a 
drachm (4.) to the ounce (32.) of cold cream, is very good. 
Dilute ammonia water is useful in some cases. Occasionally a 
saturated solution of benzoic acid in water is effectual. When 
one local remedy fails another should be tried. Irritating under- 
clothing should be avoided, and the patient should sleep in a 
cool room, with light bed covering. 

The prognosis in urticaria varies in each case. If the cause 



56 DISEASES OF THE SKIN. 

is a temporary gastric derangement, its removal will soon result 
in a cure. If, however, the urticaria is chronic and dependent 
upon some derangement of the nervous, digestive, or generative 
system of long standing, it is apt to prove very stubborn. 

URTICARIA PIGMENTOSA. 

The name urticaria pigmentosa has been given to a chronic 
inflammatory skin affection beginning in early life with urticaria- 
like lesions, some of which disappear, to recur from time to time, 
while others, once formed remain permanently. 

The disease usually begins in the first months of life, even 
in some cases a few weeks after birth. Usually wheals, but 
sometimes blebs, are first noted. The lesions are numerous and 
are chiefly seated on the trunk, but no region is exempt. Wheals, 
maculo-papules, papules or nodules, pea to almond size and of 
a yellowish color, slightly raised and irregularly rounded or oval, 
first appear. They are disseminated but occasionally appear in 
lines or with a tendency to an ill-defined crescentic arrangement. 

The lesions are at first yellowish-brown but later take on a 
dark brown color. They have a firm feeling under the finger. 
Manipulation is apt to develop an urticarial wheal. Occasion- 
ally vesicles or blebs form on the summit of the more typical 
lesions or around them, and these may have a red areola. The 
lesions, when they disappear, leave a dark brown stain or in rare 
cases a cicatrix. 

Itching, even to a distressing degree, is a characteristic symp- 
tom, but is not invariably present as in urticaria. The patient 
rubs but does not often scratch and excoriate the skin. 

The cause of the disease is obscure. While it usually begins 
in infancy, cases have been reported when the first symptoms 
appeared after puberty and even in adult age. Duhring thinks 
there are two forms of the affection, one being a persistent urtic- 
aria of a peculiar type, and the other having more the features 
of a new growth. Urticaria pigmentosa is a comparatively 
uncommon affection, only about sixty cases have been reported, 



(EDEMA ANGIONEUROTICUM. 57 

but the affection is probably by no means so rare as this would 
seem to indicate. 

Examination of sections of the lesions show appearances some- 
what similar to those found in urticaria, but in addition the 
papillary layer is filled with "mast cells" arranged in columns, 
a feature which is characteristic of the process. Sometimes 
an unusual number of mast cells is found throughout the cutis 
and extending into the subcutaneous tissue. The epidermis 
is unchanged, but for an accumulation of pigment in the basal 
layer of the rete. 

Urticaria pigmentosa is to be distinguished by the early appear- 
ance and persistency of the eruption and the yellowish stains 
which it leaves. Where the activity of the urticarial lesions 
has subsided those remaining may resemble xanthoma, but 
rubbing the hand over them will usually develop wheals. 

The ultimate prognosis of urticaria pigmentosa is favorable, the 
disease usually disappearing after puberty or after some years. 
Treatment does not usually affect its prognosis but that employed 
in urticaria, particularly the local applications, are indicated.* 

(EDEMA ANGIONEUROTICUM. 

This affection, originally called "giant urticaria," is charac- 
terized by one or more acute, circumscribed, cedematous swell- 
ings, occurring usually in localities, as the eyelid, lobe of the 
ear, lip, etc., where the tissues are lax. 

The swelling may appear without any premonitory symptoms or 
it may be preceded by malaise, and gastro-intestinal disturbances, 
which symptoms may also accompany the attack. The swell- 
ing is acute, sometimes developing in a few minutes, and may 
cause closure of the eyes, immobility of the lips, when these are 
involved, or some grotesque temporary deformity. The swell- 
ing may be of the ordinary color of the skin or it may be pink- 

*For details see Elliott, Jour. Cutan Dis., 1891, p. 296; Stelwagon, Ibid, 1898, 
P- 576; Gilchrist, Johns Hopkins Hospital Bull., vol. 'vii, 1896, p. 140; Colcott 
Fox, Brit. Jour. Derm., 1898, p. 411, and for pathologv, Brongersma, Ibid, 1899, 
p. 179. 



58 DISEASES OF THE SKIN. 

ish or reddish in color. It is harder than ordinary cedema and 
pits slightly or not at all on pressure. 

The attack occurs most frequently about the face and head, 
but the extremities are almost as frequently involved. Cases 
have been reported of the occurrence of lesions in the larynx, 
stomach and on the gums and palate. 

The swelling may last from a few minutes to hours or even 
several days. Repeated swelling may occur, prolonging the 
existence of the attack to days or even weeks. One case is on 
record in which it lasted for a year or more. The affection 
occasionally recurs. Subjectively, there is a feeling of tension or 
stiffness in the part involved with itching and burning in some 
cases. Urticarial efflorescences occasionally occur in connection 
with the localized cedema. Partial anaesthesia or numbness 
is also noted at times. 

Angioneurotic cedema is met with in both sexes and at all 
ages. It is closely allied to urticaria and probably is produced 
by the same causes. In some cases there is a family predispo- 
sition. Articles of food which cause indigestion and the produc- 
tion of gastric or intestinal toxins favor the occurrence of an 
outbreak, which is also found to occur in neurotics. Exciting 
causes are indigestible foods, alcoholic beverages, exposure to 
cold, malaria, traumatisms, etc. 

The affection is of angioneurotic origin — a vaso-motor neurosis 
similar in its pathology to urticaria. 

The occurrence of suddenly appearing, circumscribed, swellings 
of hard cedema resembling a sort of magnified urticaria is charac- 
teristic and it is almost impossible that this affection can be mis- 
taken for any other skin disease. 

The affection, except when it occurs in the air passages, is not 
of any great severity. The individual attacks are to be combated 
by strict attention to diet, freedom from worry, and the local and 
general treatment recommended under urticaria.* 

*See Quincke, Monatshefte j. Prakt. Derm., 1882, p. 129. Osier, Internat. Jour. 
Med. Sci., 1888, p. 362. Elliott, Jour. Cut. Dis., 1888, p. 19. Hartzell, Univ. Med. 
Mag., 1890. Wende, Jour. Cut. Dis., 1899, p. 178. 



PITYRIASIS ROSEA. 59 

PITYRIASIS ROSEA. * 

Pityriasis rosea is a mildly inflammatory disease of the skin, 
characterized by the appearance of more or less numerous fawn 
colored or reddish macules or circinate lesions, slightly infil- 
trated and covered with small fine scales. 

The eruption is exanthematic in appearance and onset. There 
is usually an initial lesion, consisting of a ring-formed lesion from 
one to several inches in diameter, closely resembling ring- worm 
of the skin. This is ordinarily situated on the trunk, but may 
occur elsewhere. A week or ten days after the appearance of 
the initial lesion, a more general eruption breaks out, sometimes 
accompanied by slight febrile disturbance, urine of high gravity 
with urates (Gilchrist), and occasionally post-sterno-mastoid and 
submaxillary glandular enlargement. The fauces may also be 
slightly reddened. More frequently the generalized eruption 
appears gradually and quite without general disturbance. It 
commonly commences upon the flanks or on the abdomen, but 
may begin on the upper part of the chest, the side of the neck 
and occasionally on the face or arm. It may spread over the 
body and limbs, but is usually sparse or absent below the elbows 
and knees or on the face. 

The eruption consists of discrete or confluent macular or 
maculo-papular lesions, from a pin-head to a half-dollar size, 
slightly or not at all raised. The color of the lesions is rosy or 
pale red with a more or less tawny or yellowish tint. The sur- 
face is always dry and slightly scaly, and there is a tendency to 
heal in the centre, giving a circinate appearance. Once fully de- 
veloped the eruption may last from two weeks to several months 
or occasionally much longer. The latter is rare, however. 

Pityriasis rosea is not a very uncommon disease, occurring 
about once in five hundred cases of skin disease, according to 
the American statistics. 

In itself it is a comparatively trifling affection, but gains im- 

* The name pityriasis maculata et circinata I prefer, as more descriptive, but 
pityriasis rosea is the term in most common use. 



60 DISEASES OF THE SKIN. 

portance from the fact that it is very apt to be mistaken for the 
early macular syphilitic eruption. 

The latter, however, may usually be distinguished by that 
tendency to polymorphism which is so characteristic of syphilis. 
Careful search will almost always show some lesion at one point 
or another which is characteristic of the syphilitic disease. The 
glandular involvement is more marked in syphilis. Mucous 
patches in the mouth are common at this stage of the disease 
and it is not too late, in many instances, to trace the remains of 
the chancre. Nevertheless, I have seen some of the most emi- 
nent dermatologists puzzled over doubtful cases, and time only 
brings out some characteristic feature. A too hasty decision in 
favor of syphilitic disease is to be depreciated in doubtful cases.* 

The circinate lesions somewhat resemble psoriasis, but they 
are less elevated and less scaly, lacking the hyperemic papillae, 
and do not occur conspicuously in the psoriasis localities. Ec- 
zema seborrhoicum, of the variety formerly known as "sebor- 
rhcea sicca" or "papulosa," is usually confined to the area over 
the sternum and between the shoulders. The lesions are more oily 
and thicker and the scales are much thicker and often greasy. 

The initial lesion of pityriasis rosea is readily mistaken for 
ring-worm of the body. In some cases only a careful micro- 
scopic examination will show the presence of fungi in the latter 
case. I have, moreover, repeatedly seen cases treated for tinea 
circinata for several weeks until the outbreak of the general 
eruption determined the true character of the initial lesion. 

The pathology of pityriasis rosea presents little interest. 
Unna compares the process to that of flat papular seborrhoic 
eczema, but with more oedema and spindle cell multiplication 
and no micrococci or other recognizable microbe in the scales. 

The prognosis of pityriasis rosea is always favorable, although, 
in some cases, the eruption seems perfectly rebellious to treat- 
ment and only gets well in its own good time. 

The treatment must vary in different cases. Usually the dis- 

* Renaut (Annates de Derm, et de Syph., 1891, p. 163) reported a case illustrating 
the simultaneous occurrence of p. rosea and syphilitic roseola with chancre. 



DERMATITIS EXFOLIATIVA. 6 1 

ease tends to get well spontaneously. Crocker has found sal- 
icin, in fifteen-grain doses three times a day, to hasten involution. 
He recommends locally a lotion of "liq. carbonis detergens" and 
liq. plumbi subacetat dil, of each 5ij (8) to aqua rosae 5 vn j 
(256). This is especially useful where there is itching. I have 
found the following ointment of service: 

T^. Hydrarg. oxid. flav., 5ss ( 2.) 

Petrolati, 5j (32.) M. 

Another useful ointment is the following: 

1$. Acid salicylic, 9i ( 1 20) 

Sulphur precipitat., 5 j ( 4- ) 

Petrolati, o j (32. ) M. 

DERMATITIS EXFOLIATIVA. * 

Dermal il is exfoliativa is an inflammatory disease of the skin, 
characterized by redness and exfoliation over a part or the whole 
surface, arising as such or supervening on other scaly affections, 
acute or subacute in type and of variable duration. 

The disease may begin insidiously in one or more limited areas, 
particularly about the axillae, genito-crural region or other flex- 
ures, and spread rapidly, or it may involve most or all of the sur- 
face at once. Occasionally it may be limited, as to the extremites 
alone. 

The outbreak is usually preceded by chilliness, malaise, some- 
times vomiting, and fever which may or may not continue. The 
skin is at first red with slight infiltration which, later, may become 
more pronounced. Exfoliation soon begins in the form of thin, 
variously sized scales or flakes of a dirty gray or brownish tinge ; 
the underlying skin is smooth, red and shiny and later has a 
yellowish cast. There is at times considerable burning and 
itching. After some weeks or months the process begins to 
abate, the skin loses its inflammatory aspect, is less red, and the 
exfoliation is less marked and less rapid, and the malady comes 
to an end. In other cases, after a longer or shorter time a relapse 

* See Stelwagon, Diseases of the Skin, 4th ed., 1905, p. 185, for fuller description 
with bibliography. 



62 DISEASES OF THE SKIN. 

occurs, and this may be repeated indefinitely. Occasionally the 
recovery is permanent. 

In persistent cases the patient's health is apt to suffer and 
complications supervene; arthritic troubles, involvement of the 
mucous surfaces and internal organs, furuncles and abscesses, 
loss of hair and nails may occur. Some cases of dermatitis 
exfoliativa envolve from psoriasis or eczema. A great variety 
exists in the symptoms, for the description of which the student 
is referred to the numerous monographs and reports of cases. 

The etiology of dermatitis exfoliativa is obscure. None of 
the various causes heretofore assigned seem to be satisfactory. 

The pathology, like the etiology of the disease, is somewhat 
obscure. In milder cases there is little more than hyperemia 
while in severe cases considerable inflammatory and atrophic 
changes occur. In the extreme varieties there is a complete oblit- 
eration of the papillae with variable atrophy of the interpapillary 
rete prolongations. The glandular structures disappear in part 
or wholly and pigment-granule deposit is noted in the lower 
epiderm. Other and more extensive changes have been noted 
by observers. 

The diagnosis of dermatitis exfoliativa may be difficult in the 
first few days of the outbreak but the nature of the affection 
becomes manifest after continued observation. From scarlet 
fever and from erythema scarlatinoides it is differentiated by 
the (usual) absence of systemic involvement or sore throat. The 
absence of blebs as a feature is an important point of difference 
from pemphigus foliaceus. Psoriasis and lichen ruber are rarely 
if ever universal, the skin is more thickened, and in the former, 
the scales are more abundant. The beginning papular character 
of the latter and the presence of typical papules here and there 
at the borders of areas, even when the disease is extensive, 
are sufficient to prevent error. In generalized eczema there 
will almost always be found oozing and discharge somewhere, 
or at least the history of such. In eczema there is a tendency 
to thickening of the skin, never to thinning and atrophy. 

The prognosis of dermatitis exfoliativa varies with the charac- 



DERMATITIS EXFOLIATIVA. 63 

ter of the case. Milder cases will pretty surely recover, though 
relapses may be feared. In the more severe cases the disease 
tends slowly but almost inevitably to a fatal termination, through 
exhaustion and the development of internal complications. 

The general treatment should be strengthening and sustaining. 
Among drugs arsenic and sodium salicylate are most generally 
useful. Otherwise the treatment should be governed by general 
principles. The local treatment is important. Cooling and 
soothing ointments, as carbolized petrolatum, cold cream, etc., 
are of value. Warm baths followed by inunction may also be 
practiced. 

DERMATITIS EXFOLIATIVA EPIDEMICA. 

Epidemic exfoliative dermatitis is a rare affection, most of the cases de- 
scribed having occurred in certain infirmaries under care of Dr. Savill (Brit. 
Jour. Dermatol., vol. iv, 1892), and in almshouses, etc. The affection in some 
of its aspects resembles eczema and in some, ordinary exfoliative dermatitis. 

The eruption is not preceded by severe signs or symptoms, although vomit- 
ing and anorexia may occur with diarrhoea and sore throat. The occipital 
and cervical glands and occasionally the maxillary are enlarged. The upper 
limbs, face and scalp are usually first attacked. A sensation of itching is ex- 
perienced and then numerous acuminate red papules appear, irregularly 
grouped and seated at the follicles. These remain unchanged or coalesce into 
red patches and the eruption spreads over the body with greater or less 
rapidity until the entire surface is involved in a deep red infiltration covered 
with abundant flakey scales. In some cases vesicles form and break, present- 
ing a raw eczemaform surface. The disease runs its course in six or eight 
weeks. Relapses are not uncommon. Occurring in almshouse there is five to 
thirteen per cent of mortality. Death usually occurs from exhaustion with 
coma, subsultus tendinum, etc. Sometimes pneumonia, gangrene of the feet, 
etc., occur and albuminuria is not uncommon. The cause of the disease is 
unknown. 

DERMATITIS EXFOLIATIVA NEONATORUM. 

Under this name Ritter (Vierteljahrsschr. j. Derm. u. Syph., Hft., 1, 1879) 
described an eruption which he observed in the Foundling Asylum at 
Prague. The affection begins in the first or second week of life, and occa- 
sionally as late as the fifth, usually in the lower part of the face first, but it 
may begin anywhere. The lesions are red, scaly patches soon becoming uni- 
versal with fine branny or lamellar desquamation like exfoliative dermatitis 



64 DISEASES OF THE SKIN. 

of adults. In some cases there are vesicles or flaccid bullae like pemphigus 
foliaceus and then there are crusts as well as scales, with rhagades about the 
mouth and anus. There is no fever nor general symptoms. Half of the 
cases die of marasmus with or without diarrhoea. In favorable cases the 
disease runs its course in eight or ten days, though relapses may occur. Boils, 
abscesses and gangrene may occur as sequelae* 

PRURIGO. 

Prurigo is a chronic inflammatory disease, characterized by 
numerous, discrete, rounded, small split-pea-sized, solid, firmly 
seated, slightly raised, pale red papules, accompanied by general 
thickening of the skin and intense and constant itching. It 
is an excessively rare disease in this country. The American 
statistics show only 34 cases in 123,746 of all varieties of skin 
disease. It usually begins at an early age, within the first or 
second year, in the form of an urticaria (see Urticaria pigmen- 
tosa) and commonly lasts through life. When developed it 
consists of firm, pin-head to pea-sized elevations under and in 
the skin, usually discrete, but sometimes grouped. The color of 
the lesions is pale red, or like the surrounding skin; there are no 
scales. The disease usually first attacks the extensor surface 
of the lower extremities, particularly the tibiae. The forearms are 
next invaded, and then the trunk. The head is rarely attacked ; 
the palms and soles never. In severe cases buboes may form in 
the glands of the inguinal regions. 

The eruption is accompanied by intense itching and conse- 
quently blood crusts are always present, and in time the hairs are 
torn and rubbed off, and the skin becomes harsh, thickened, and 
pigmented. 

The pathologic changes are similar to those in eczema, they 
have been carefully studied by Taylor and Van Gieson, (2V. Y. 
Med. Jour.), vol. liii, 1891, p. 1. 

The diagnosis of prurigo is not difficult. The disease has 
a distinct and well-defined history, which prevents it from being 

*See Patek. Dermatitis Exfoliativa or Ritter's Disease, Jour. Cut. Dis., 1904, 
p. 269. 



LICHEN RUBER. 65 

mistaken for eczema. Eczema, indeed, often accompanies pru- 
rigo, being aroused by scratching or the application of reme- 
dies, but this can be cured by appropriate treatment, while 
the prurigo goes on, unaffected by treatment. Pruritus is un- 
accompanied by papules. Pediculosis can be verified by a search 
for the parasitis and also by noting the localities attacked. (See 
Pediculosis corporis.) 

The treatment of prurigo should be first directed to the general 
condition of the patient. The diet should be generous. Every- 
thing that will tend to improve the state of the patient's health 
is to be taken into consideration. Iron, arsenic, quinine, and 
especially cod-liver oil, may be prescribed. External remedies 
are particularly useful. Baths of various kinds, and also tar, 
naphthol, and sulphur applications, are particularly to be men- 
tioned. 

The prognosis of prurigo is not very hopeful. It is said to be 
curable if treatment is commenced in childhood, but scarcely 
so in the adult. If a case is reported as having been easily cured, 
it is probably because a mistake lias been made in diagnosis. 

LICHEN RUBER. 

Lichen ruber is an inflammatory disease characterized by 
pin-head to pea-sized flat and angular, or acuminated papules, 
smooth and shining, or scaly, deep red, discrete or confluent, 
and running a chronic course attended by more or less itching. 

There are two varieties as commonly described, lichen ruber 
acuminatus and lichen ruber planus* 

Lichen ruber acuminatus (the pityriasis rubra pilaris of some 
writers) is characterized by the development of hard, dry papules 
situated at the hair follicles; they may be pale yellow, pink or 
red, and under a lens show an atrophied hair in the centre, sur- 
rounded by a sort of horny sheath which penetrates into the follicle. 

*See R. W. Taylor, "Lichen Ruber as observed in America, and its distinction 
from Lichen Planus," N. Y. Med. Jour., Jan. 5, 1889, and A. R. Robinson, 
"The Question of Relationship between Lichen Planus and Lichen Ruber." Jour. 
Cutan. and Gen-Urinary Dis., Jan., Feb. and March, i88q. 

5 



66 DISEASES OF THE SKIN. 

The papules are about pin-head size and are seen most abund- 
antly on the backs of the hands, on the back of the first and slightly 
on the second phalanges, wrists, forearms, elbows and knees. 
They are also found on the trunk. These papules though 
most characteristic are not usually the first lesions. More fre- 
quently the first parts attacked are the palms and soles. In 
extreme cases the eruption is universal and the whole surface is 
dry and scaly. 

Anatomically there is increased cornification of the epithelial 
wall of the orifice of the follicle to which the dermal changes are 
probably secondary. Unna states that the horny papule may 
form at a sweat orifice as well as at a hair follicle, or independ- 
ently of either, and that there is also a general hyperkeratosis of 
the surface. In the severer forms the other changes are those 
found in chronic forms of dermatitis, e.g., prurigo. 

The diagnosis of lichen ruber acuminatus ' is determined in 
mild cases by the presence of follicular papules, with a horny 
plug in the orifice of the follicle which can be picked out and 
produces a cribriform aspect; the dry scaliness of the palms, soles, 
scalp and face; the absence of any disturbance of the general 
health — in other words its benign course as compared to most 
forms of universal dermatitis. In the severe forms the develop- 
ment is more rapid, with marked constitutional symptoms. The 
diseases it most resembles are pityriasis rubra or dermatitis 
exfoliativa and psoriasis. 

Lichen ruber acuminatus is rare. The treatment is like that 
employed for the planus form of the disease excepting that arsenic 
often fails to be of use. 

Lichen ruber planus is the form most commonly met with. It 
is characterized by an eruption of papules, varying in size from 
a pin-head to a split-pea; often they coalesce and form patches. 
The shape of the papules is peculiar and charactertistic ; they 
are seldom round, as most papules, but are, instead, quadrangu- 
lar or polygonal in form. They rise abruptly from the skin to the 
sixteenth of an inch or less, are flattened on the summit, and show 
a minute umbilication with whitish puncta. To the touch, 



LICHEN RUBER. 67 

they are firm, smooth, and without scales, excepting in those 
cases where the disease runs into a papulosquamous stage. 
They are glazed, and of a peculiar dusky, crimson, or even vio- 
laceous tint. Usually discrete, the lesions are sometimes aggre- 
gated, so as to form sheets of raised and infiltrated lesions. 

The diffuse form of the disease is rarely seen in this country. 
It is made up of large patches of acuminate lesions. Itching 
is generally present in both varieties of the disease. It is usually 
moderate, but may at times be severe. The commonest locality 
of lichen ruber planus is on the forearms, especially upon the 
flexor surfaces of the wrists. It occurs also on the palms and 
soles, on the penis and elsewhere. It is apt to be symmetrical, and 
the lesions are sometimes arranged in rows. The course of the 
disease varies; in some cases, under careful treatment, a cure 
can be effected in a few weeks or months, while other cases run 
an exceedingly chronic course, even extending to years. Per- 
sistent, dark brown, or violaceous stains succeed the lesions. 
The severer forms are said to run a graver course, and to end 
sometimes in marasmus and death. 

The cause of lichen ruber is generally to be found in exhaustion, 
nervous debility and depression, overwork and improper diet, 
leading to impoverished nutrition. 

The pathologic anatomy of lichen ruber planus has been 
studied by Robinson and others. The disease has its seat in the 
upper part of the corium and usually around a sweat duct. The 
rete and horny layer are thickened, and the papilla? enlarged, the 
vessels of the latter showing dilatation. In some recent papules 
however the corneous layer may be slightly thinned. The central 
point of the depression usually corresponds to the sweat duct ori- 
fice. The sweat glands are not affected. In lichen ruber planus 
the hair follicles have no determining influence on the situation 
of the papules. 

Lichen ruber may be mistaken for the papular syphiloderm, 
which it closely resembles, especially in the coppery or ham color 
of the lesions. In the variety L. ruber planus, however, the 
peculiar shape and contour of the lesions, with their smooth, 



68 DISEASES OF THE SKIN. 



umbilicated, or punctate surfaces, will serve to distinguish them.* 
Eczema papulosum, which often resembles lichen ruber, differs in 
that the papules are roundish, somewhat acuminate, bright red 
in color, and intensely itchy. Their evolution also is different. 

The internal treatment of lichen ruber should be chiefly tonic 
and supporting. Arsenic is of high value, and is, in fact, almost a 
specific. The dose, at first two to four minims (0.13-0.26) of Fowler's 
solution, in a fluidrachm (4.) of wine of iron, should be increased al- 
most to the limit of tolerance, and persisted in. Arsenic may also 
be administered hypodermically, using one part of Fowler's solution 
and five parts of water, beginning with four or five minims (0.26- 
0.33) of the mixture. The preparations of iron and cod-liver oil 
are also useful. Valerian, the bromides, tincture of belladonna, 
2 -grain (0.13) pills of carbolic acid, up to eight daily, may relieve 
the itching. If an urticarial element is present, quinine and 
ergot may be employed if belladonna fails. Treatment should 
be instituted early in the course of the disease. Cases of long 
standing are very stubborn, even to the best directed treatment, 
which, earlier given, might have proved effectual. 

Locally, simple ointments, as vaseline or cold cream, may be 
employed when itching is not present. When the eruption itches, 
alkaline baths, carbolic acid washes or ointment, dilute hydrocy- 
anic acid, with water, diluted "liquor picis alkalinus, " made 
thus: 

1$. Potassae caustic, gr. xv ( i.) 

, Picis liquids, gr. xxx ( 2.) 

Aquae, f§iv. (128.) M. 

may be employed. It should be considerably diluted at first. 
The following ointment is a useful one: 

1^. Olei rusci crudi (vel. ol. betulae), 3j (4-) 

Ung. aquas rosae, § j (32.) 

Ol. rosae, rt\xv. ( 1.) M. 

In addition to these, the more stimulating and stronger anti- 

*Dubreuilh and Le Strat, Ann. de Derm, et de Syph., 1902, p. 209, give the dif- 
ferential diagnosis between lichen planus and other affections of the palms and 
soles. 



LICHEN SCROFULOSUM. 69 

pruritic remedies mentioned under the head of eczema may be 
employed, with the hope of reducing the pruritus and bringing 
about absorption of the lesions. The following ointment has 
proved of high value: 

T\. Hydrarg. bichlor., gr. ij-iv ( 0.13-0.25) 

Acidi carbolici, gr. x-xx ( 0.65-1.3 ) 

Ung. zinci oxidi, o j. (32.) M. 

Hot douches and compresses, once or twice daily, often give 
relief in severe cases. Occasionally removal from ordinary 
surroundings, and especially a sojourn at high altitudes, may 
be required. Chrysarobin, a 10 per cent, solution in chloroform 
or as an ointment, is sometimes useful in chronic cases. Of late 
years X-ray treatment has proved valuable. 

The prognosis of lichen ruber will depend upon the extent of 
the eruption, its duration, and the patient's general condition. 
Localized eruptions of L. ruber planus on the wrists and forearms, 
occurring in persons of average health, do not usually require 
a very lengthened course of treatment for their cure. When, 
however, the eruption is extensive and severe, and has lasted a 
long while, the prognosis is much less favorable. 

LICHEN SCROFULOSUS. 

Lichen scrojulosus is an inflammatory disease, occurring chiefly 
among tuberculous children and young adults, and characterized 
by the occurrence of small papules of a red color fading into the 
skin, disposed in groups and circles, and occurring chiefly upon 
the trunk. 

The affection is not often met with in this country but is some- 
what more common in Europe. The papules are from pin-point 
to pin-head in size, slightly conical, or a bright red, fading later 
to a pale red or fawn color or even to the color of the normal 
skin, and tending to be arranged in roundish groups, circles or 
segments of circles. Sometimes these circles are filled up with 
other lesions so as to' look like an exaggerated cutis anserina 



7° 



DISEASES OF THE SKIN. 




Fig. '5. — Psoriasis, showing distribution. 



PSORIASIS. 71 

(Crocker). A minute scale is formed upon each of the other 
papules which, after lasting a few weeks to months, disappear, 
leaving small, yellowish, pigmented spots. 

The eruption is usually limited to the trunk, but in some cases 
occurring in children the limbs alone may be attacked. Itch- 
ing is absent or very slight. There are usually some evidences 
of a tuberculous taint. The disease is kept up by the continuous 
development of new papules so that if not cured it may run on 
for years. Occasionally a few acneform lesions occur, and now 
and then some of the papules have a horny spine projecting 
from their center. 

The lichen scrofulosus papule, as was shown by Kaposi many 
years ago, is formed by a cell infiltration of the papillae around 
the follicle, and the central scale by a collection of epidermis at 
its dilated orifice. Whether there is any actual tubercular lesion 
is a matter of question. Gilchrist* found in one case a granuloma 
deeply seated, while the folliculitis which produced the clinical 
symptoms was more superficial. 

The small size and pale red color of the papules, their peculiar 
arrangement in groups and circles, their usual limitation to the 
trunk, the youth of the patient and the absence of itching are 
the most distinguishing features. The frequent concurrence 
of tuberculosis in some form is also characteristic. The af- 
fection is to be distinguished from eczema, certain follicular 
syphilodermata, punctate psoriasis and true inflammatory lichen 
pilaris. 

The prognosis of lichen scrofulosus is favorable. Cod-liver 
oil internally and externally always removes the eruption. 
The dose should be small at first and gradually increased. 

PSORIASIS. 

Psoriasis. — Psoriasis is a chronic inflammatory disease of the 
skin, characterized by reddish, slightly elevated, dry, roundish 
or circular patches, variable as to size and number, covered with 

* Johns Hopkins Hosp. Rep., 1899, p. 84. 



72 



DISEASES OF THE SKIN. 




Fig. 6. — Psoriasis, showing distribution. 



psoriasis. 73 

abundant whitish or grayish mother-of-pearl-colored, imbricated 
scales. The disease varies greatly in its extent and intensity 
in different cases, sometimes showing a typical development ; in 
other cases represented by one or two obscure lesions. It pos- 
sesses, almost invariably, however, certain characters which serve 
to identify it. The lesions begin as small, reddish spots, scarcely 
raised above the level of the skin, which almost immediately 
become covered with whitish, imbricated scales. They often 
develop rapidly, reaching the size of coins in a few week-. At 




Fig. 7. — Psoriasis showing, characteristic appearance and distribution on legs 

other times the course of the disease is more sluggish. The ex- 
tent of the eruption varies greatly. A few patches may be all 
that are present, or the entire surface from head to foot may be 
involved, with scarcely a clear spot to be found. Commonly, 
the disease shows itself in the form of variously-sized, scaly 
patches, scattered over different parts of the body. The patches 
are characteristic. They are usually rounded, sharply defined 
from the surrounding skin and consist of a mass of imbricated, 



74 



DISEASES OF THE SKIN. 



yellowish- white scales on a red base. When the scales are picked 
off, a smooth, shiny, reddish surface is shown underneath, on 
which can be perceived a few pin-point-sized drops of blood. 
The abundance of the scales is a marked feature in some cases; 
where they are formed rapidly, that is, in well-developed cases, 
the patient's bed may be filled in the morning with a handful 
of scales which have accumulated during the night. When the 
disease exists about the joints, fissures may show themselves. 
There is no watery discharge at any period of the disease. Some- 
times the eruption takes on a highly inflammatory character, 
with redness, swelling, and severe burning and itching, while 




Fig. 8. — Psoriasis. Local appearance. (Courtesy of Dr. Knowles.) 



at other times all these symptoms are much less marked, and, 
in fact, the patient would hardly be aware of the existence of 
the disease, except for its appearance. Though the individual 
patches of psoriasis may be small, and generally are so, yet they 
sometimes coalesce into hand-sized or larger patches, or may 
even cover the greater part of a limb. 

Psoriasis may occur on any part of the body, but is most apt 
to be seen on the extensor surfaces of the limbs. It is sometimes 
found on the elbows and knees when it shows itself nowhere 
else. The back is more commonly attacked than the chest, and 
the scalp is a frequent seat of the disease. In the latter locality 



PSORIASIS. 



/b 



it sometimes occurs in patches, but more frequently as a diffuse 
and abundant scaliness. It is apt to extend a little beyond the 
border of the scalp, especially behind the ears and on the forehead, 
and this is quite characteristic. Psoriasis does not occur upon 
the mucous membranes. The so-called "psoriasis of the tongue " 
is an entirely different condition. In rare cases, as White has 
pointed out,* psoriasis may degenerate into verruca, keratosis and 
then into cancer. Cases of cancer occurring after psoriasis have 
been attributed to the prolonged use of arsenic. Both possibil- 
ities should be borne in mind. Psoriasis is not contagious. 

Psoriasis is among the more common diseases of the skin, 
being met with in this country in the proportion of 3 per cent, of 
all skin diseases. It is apt to occur in well-nourished, rosy- 
complexioned, light-haired people, the "picture of health," 
excepting that they are apt to be a little rheumatic. Now and 
then, however, it is met with in thin, worn persons, who are in 
poor health. Psoriasis rarely occurs in children, though Stelwagon 
has reported a case where it occurred in a child between three 
and four years of age, and even younger cases have been reported.! 
It does not often appear to be hereditary, but this tendency is 
occasionally met with. Some cases of psoriasis are worse in 
winter, and disappear almost or entirely in summer; others are 
worse in summer. Diet, I think, has usually little influence in 
causing the disease, though in some cases it may influence its 
course quite markedly. J 

Psoriasis and syphilis are not connected in any way. There is 
a syphilitic eruption, sometimes called "syphilitic psoriasis," 
because the lesions resemble those of psoriasis. This most un- 
happy term has caused much confusion of mind, but it must be 
remembered that the cause, course, and treatment of syphilis differ 
in toto from those of psoriasis. (See Sy philoderma papillosum.) 

The pathogenesis and the proper interpretation of the his- 
topathological changes in psoriasis are unsettled problems. 

* J. C. White, Am. Jour. Med. Sri., Jan., 1885. 
tSee Crocker, Diseases of the Skin, 3d Ed., Phil., 1905, p. 365. 
I Vaccination sometimes brings out an eruption of psoriasis, cf. Aronheim, Mon- 
atslicjte /. Prakt. Dermatol., 1900, v. 30, p. 545. 



6 DISEASES OF THE SKIN. 



Some cases suggest a trophoneurotic or vaso-motor origin, others 
appear to be toxic and dependent on systemic conditions. A 
theory of parasitic origin has been maintained by some distin- 
guished observers.* 

Microscopically the lesions, in the corium, especially in the 
papillary and subpapillary portions, show evidence of subacute 
or chronic inflammation. There are vascular dilatation, moder- 
ate oedema and infiltration of polymorphoneuclear and round 
cells especially around the vessels. The papillae are elongated. 
The rete shows marked hyperplasia, especially of the interpap- 
illary processes. There is intercellular oedema, the transitional 
layers are partially or totally absent and the process of cornifi- 
cation is incomplete, the outer cells retaining their nuclei. 

The diagnosis of psoriasis is easy when the affection is well- 
developed and presents its typical appearance. The form and 
aspect of the lesions, and the history of the case, will usually 
serve to determine its nature. Scanty and ill-developed eruptions 
of psoriasis are, however, at times, distinguished only with diffi- 
culty. Nevertheless, it is an important matter to accurately 
determine the nature of the disease, for its treatment is widely 
different from that of the affections with which it is liable to be 
confounded; its prognosis also is different, and in addition two 
of the other affections are contagious. 

Two or three small patches of psoriasis occurring alone, upon 
the arms or legs, may be mistaken for eczema. Itching, however, 
is always present in eczema, and, therefore, itching is one sign 
that an eruption in question is not of this nature, though not a 
sure one, since psoriasis also sometimes itches. 

In the majority of cases of eczema, there will be a history of 
moisture at some time. Psoriasis is always dry and scaly; 
never moist. The scales of psoriasis are more abundant, larger, 
and whiter than those of eczema. The patches of psoriasis are 
usually bold and well-defined in outline, while those of eczema 
fade into the surrounding skin. 

*See Hyde and Montgomery. Diseases of the. Skin, Phil., 1904, for discussion 
and bibliography. 



psoriasis. 77 

Syphilis, in the form of the papulo-squamous syphiloderm, 
is very apt to be mistaken for psoriasis, and vice versa. Psoria- 
sis, however, is more apt to be symmetrical in its distribution. 
It inclines to involve a large portion of the surface at once, or to 
be found in regions remotely separated, which the squamous 
syphilitic eruption rarely does. In psoriasis the lesions seem to 
be on the surface, so to speak. They are very scaly, but without 
much infiltration. The syphiloderm, on the other hand, is 
deeply indurated, and is only scantily covered with scales. In 
psoriasis the knees and elbows are apt to be involved. In syph- 
ilis these are not often attacked. Occurring on the palms or 
soles, the disease is apt not to be psoriasis, which is very rare in 
this locality. The color, though often deceptive, sometimes aids 
in diagnosis. It is usually much lighter in psoriasis, while in 
syphilis it is apt to be a dusky, ham color. The age of the patient 
and the duration of the disease may give a clue to the diagnosis. 
Psoriasis generally first shows itself before the age of twenty; 
this form of syphilis later. The history of psoriasis is that of 
a chronic disease, lasting for years continuously, or in an inter- 
mittent manner. Syphilis rarely retains one form for any length 
of time. Other points in the history; infection, the occurrence 
of other lesions, etc., may come into use. Itching is rare in syph- 
ilis, rather common in psoriasis. Finally, the "touchstone of 
treatment" may be resorted to in very obscure cases. 

Tinea circinata and psoriasis are sometimes mistaken for one 
another, but the patches of tricophytosis are less inflammatory, 
red and infiltrated, and are much more superficial. The scales 
in tricophytosis are larger and lighter, and the patches show 
no attempt at symmetry. The microscope shows the existence 
of a fungus in the scales of tricophytosis circinata, which is 
absent in psoriasis, and a history of contagion may often be 
obtained in the former disease which is absent in the latter. 

Psoriasis may occasionally be mistaken for eczema seborrhce- 
icum, as this disease occurs on the chest and back. It may also 
be confounded with severe forms of lupus. A comparison of 
the description just given of psoriasis with that of the two for- 



7© DISEASES OF THE SKIN. 

mer diseases will show in what points the difference lies. Pso- 
riasis may likewise be mistaken for lichen ruber or lupus ery- 
thematosis. (See under diagnosis of these affections.*) 

The constitutional treatment of psoriasis, should be based 
on a careful study of the history and habits of the patient. 
Attention should be given to the patient's general health 
and his condition, whether stout and well-nourished, or thin 
and delicate. Regard must be had also to any functional 
derangement. The history of the eruption itself must also be 
inquired into, as to its acuteness or chronicity, as to local and 
constitutional treatment which may have been previously em- 
ployed, together with the effects of the same. In addition, 
inquiry should be made regarding the influence of the seasons, 
and whether the eruption is apt to disappear for a time and 
to break out again. 

Fortified with this knowledge, the medical treatment can be 
entered into intelligently. In the large majority of cases arsenic 
is preeminently the remedy. But, while arsenic is as near 
a specific as, in the nature of things, it is possible for any medicine 
to be, yet it must be employed judiciously if its good effects 
are to be obtained, or even if we do not wish to do harm. Arsenic 
should not, as a rule, be given where there is much gastric irri- 
tation, and it is hardly necessary to say that it should not be con- 
tinued, should it disagree even slightly. The patient should be 
warned of its possible effects, and should be under the constant 
guard of the physician; on the first symptom of indigestion, 
pain in the stomach or bowels, or diarrhoea, the dose should be 
lessened or the use of the medicine suspended. Large or almost 
toxic doses do not hasten the cure of psoriasis; they sometimes 
even retard it by upsetting the stomach. Sometimes only a 
minute dose, as half a minim of Fowler's solution, is borne at 
first, when, later, tolerance is gained and a full dose can be 
given. Some patients need and will bear large doses of arsenic, 
but this idiosyncrasy must be learned by careful, tentative 

* Cf. Diagnosis of psoriasis plantaris. Darier and others, Annates de Derm, et 
■de Syph., 1896, p. 607. 



psoriasis. 79 

increase of the dose, beginning always with a moderate one. 
Arsenic should not usually be given in acute and inflammatory 
forms of psoriasis. Arsenic acts slowly. When, in a case of 
psoriasis, it is going to do good, improvement generally begins 
to be shown after two or three weeks, but to get the full benefit 
of the drug it must be given for several months, and its admin- 
istration should be continued for several months after the erup- 
tion has disappeared. Liquor potassii arsenitis, or Fowler's 
solution, is the best form in which to administer arsenic. It 
should never be administered in drops, as mistakes are likely to 
occur. It may be given in water alone, or in a bitter infusion 
or tincture, or with wine of iron: 

1$. Liq. potas. arsenit., oij ( 8.) 

Yini ferri, ad t'oiv. (128.) M. 

Sir.. — A teaspoon ful in water, after meals. 

The dose here is four minims — a fair average dose for an 
adult. The amount may be gradually increased, say every 
three days, until an effect upon the eruption becomes percep- 
tible, or until the limit of tolerance is reached. 

Sometimes it is desirable to give arsenic in pill form : 

ly. Pulv. acidi arseniosi, gr. ij ( .13) 

Pulv. piperis nigrse, 

Pulv. glvcyrrhiz^ rad., aa 3ij. (2.60) M. 

Fiat pil. No. xl. 
Sic. — One after meals. 

Or occasionally powders may be preferred: 

1^. Pulv. acidi arseniosi, gr. ij ( .13) 

Pulv. sacch. lactis, gr. cl. (9.75) M. 

Fiat chart. No. xl. 
Sig. — One immediately after meals. 

In some stubborn cases arsenic may be given hypodermically. 
I usually use a sterilized Fowler's solution. When this gives 
rise to too much pain a 1 per cent, solution of arsenic chlorid 
in Schleich's solution may be employed. Strict antiseptic pre- 



80 DISEASES OF THE SKIN. 

cautions should be taken. The gluteal region is the best locality 
for puncture. The dose at first should be small, i minim of 
Fowler's solution or T ^j grain (0.00065) arsenic chlorid daily, 
once or twice a week gradually increased. In unskilful hands 
abscesses may be produced. 

Some cases of psoriasis require tonics. Tincture of the 
chloride of iron is the best medicine to use in those meagre, 
worn-looking persons, as nursing mothers, when the attack has 
come on during lactation. Next to iron in value is cod-liver 
oil, and these remedies occasionally succeed when arsenic fails. 
In acute inflammatory cases diuretics are occasionally of service. 
Acetate of potassium, in half -drachm (2.) doses, may be given three 
or four times a day, in a wineglass of water. The alkaline 
mineral waters are also of service. Iodide of potassium has 
been highly lauded. I have tried it repeatedly without gaining 
any benefit whatever; nor have I succeeded with salicin though 
this remedy has proved useful in some hands. On the other hand 
carbolic acid in 1 grain (0.065) dose increased has proved success- 
ful insome cases when arsenic has failed. Other drugs have been 
administered in psoriasis, but I think that those just mentioned 
will be found sufficient. 

The local treatment of psoriasis is of more or less importance, 
according to the nature of the case. When the lesions are nu- 
merous, small, and widely disseminated, and there are no disagreea- 
ble subjective symptoms, local treatment is inconvenient and need 
not be employed. When, however, there are a few large patches, 
or when the eruption is situated on some conspicuous part of 
the person, or gives rise to annoying burning or itching, local 
treatment is required and will be found advantageous. If there 
are scales, these should be first removed by rubbing with sapo- 
viridis and hot water, or by the use of a hot- water bath. If the 
patches are few in number, large and very scaly, the following 
solution, well rubbed in, will remove the scales readily, and give 
an opportunity for making healing applications: 

Py. Acidi salicylici, 5 j ( 4-) 

Alcoholis, • fo-iv. (120.) M. 



PSORIASIS. 8l 

Or, 

1$. Acid, salicylic, 3iv ( 5.32) 

Ol. ricini oiv. (128. ) 

These are especially useful on the scalp, when, after the scales 
have been cleansed off by this means or by means of "spiritus 
saponis kalinus" (two parts of sapo-viridis dissolved in one part 
of hot alcohol and filtered), used as a shampoo, an oil composed 
of one drachm of oil of cade to the ounce of oil of almonds or of 
alcohol may be well rubbed in by the aid of a soft brush. On 
the edge of the scalp and about the face the best ointment is 
that of ammoniated mercury, twenty to forty grains (1.30 to 
2.60) to the ounce. 

When it is desirable to get rid of the scales and patches in 
the most rapid manner possible, chrysarobin (chrysophanic 
acid) is the best application. An ointment of half a drachm to a 
drachm (2.-4.) to the ounce (32.) is very efficient , and will remove 
a patch in a few days, leaving a white spot of skin surrounded 
by a purplish areola in its place. But there are strong objections 
to the use of chrysarobin. It discolors everything with which 
it comes in contact, dyes the hair orange-yellow, and ruins the 
clothes. It cannot be used on the scalp, nor about the eyes 
and cheeks, because it induces a pseudo-ervsipelatous dermatitis 
there, and it cannot be trusted in the hands of most patients, 
because, unless used cautiously, it may inflame the skin wherever 
used. G. H. Fox has suggested the following solution, which 
is quite effectual and saves the smearing which renders the chrysa- 
robin ointments so annoying and disagreeable: 

1$. Chrysarobin, 5j ( 4-) 

^Etheris et alcoholis, aa q. s. 

Collodii, 5 j. (32. ) M. 

Rub up the chrysarobin with a little alcohol and ether, and 
add the collodion. It forms a sort of emulsion, which should 
be shaken before using. By the aid of a camel's-hair pencil in 
the cork, this may be painted over the affected patches after 
removal of the scales. When it dries, it will not come off on 
the clothes, a great advantage. 
6 



82 DISEASES OF THE SKIN. 

Next to chrysarobin in activity comes pyrogallic acid. This may 
be used in ointment— a drachm to the ounce (4. to 32.). It is not so 
effectual, but is much more cleanly, although it leaves a blackish 
stain. I think it the best local application for psoriasis. The 
only caution to be observed is, not to rub it over a large area, 
say a quarter of the surface of the person, at any one time, for 
fear of absorption. 

The following combination may be used after the scales have 
been removed by a bath: 

Ify. Acid, pyrogallic, gr. xij ( 0.72) 

Acid, salicylic, gr. viij ( 0.48) 

Collodii flexile, f 5 j. (32. ) M. 

The ingredients may be dissolved in some appropriate men- 
struum or suspended in the collodion. A brush should be 
inserted in the cork for convenience in painting on. The applic- 
ation should extend a little beyond the patch. 

Preparations of tar have been used from time immemorial 
in the treatment of psoriasis, but I think the remedies above 
mentioned are better, and they are certainly much more agree- 
able. When there is a good deal of itching, however, tar may 
be used, either as an ointment, of one to two drachms (4. to 8). 
to the ounce (32.), or in the following formula: 

1$. Saponis viridis, 
Picis liquidae, 
Alcoholis, aa, 5iv. (16.) M. 

This is to be rubbed firmly into the patches, previously denuded 
of scales, twice daily. Hebra's modification of Wilkinson's 
ointment : 

1$. Flor. sulphuris, 

Ol. cadini, aa oiv (16. ) 

Sap. viridis, 

Adipis, aa oj (32. ) 

Creta prep., 3ii ( 8. ) 

is useful. 



ECZEMA. 83 

In very severe and extensive, or in universal psoriasis, baths 
with inunctions of bland oils and fats are better than any of the 
applications mentioned. Tar may be used in these cases, with 
caution. 

The prognosis of psoriasis, so far as the individual attack 
is concerned, is, in medium and mild cases, usually favorable. 
But the disease is prone to relapse, and the physician should 
warn his patient that, while the attack can be cured, the affection 
is liable to return, and that no treatment, however well directed, 
will surely prevent the disease from coming back. Severe 
cases, especially when the entire surface is covered with the 
disease, are often rebellious to all treatment. 

ECZEMA. 

Eczema is an inflammatory, acute or chronic disease of the 
skin, characterized at its commencement by erythema, papules, 
vesicles or pustules, or a combination of these lerions, accom- 
panied by more or less infiltration and itching, terminating either 
in discharge, with the formation of crusts, or in desquamation.* 

Eczema is one of the commoner forms of skin disease met 
with in this country, occurring in the proportion of about 27 per 
cent, of all cutaneous affections. 

It is eminently a protean disease. At one time it begins as 
an erythema; later this may become moist and secreting, and 
finally terminate in a thickened, dry, and desquamative surface. 
At another time the affection may begin in the form of vesicles or 
pustules, with swelling and heat. These soon burst, and a red 
weeping surface results, which is soon coated with bulky crusts 
from the drying of the liquid, gummy discharge. The character 

*This definition of eczema is a good working one and is sufficiently character- 
istic to designate the affection from a clinical standpoint. It would take pages to 
present an adequate picture of the protean character of the disease. This is given 
so far as possible in the description of the various forms of the affection in the fol- 
lowing pages. Under the pathology of the disease will be found some mention of 
the various theories of its origin. In the present unsettled condition of our views 
as to the nature of eczema nothing very definite can be asserted. (Cf. The 
Passing of Eczema, by J. Nevins Hyde, Jour. Cut. Dis., 1904, p. 30.) 



84 DISEASES OF THE SKIN. 

of the patch may then suddenly change, and instead of a weep- 
ing surface there may exist a dry, scaly, infiltrated, fissured patch 
of skin, which continues until the disease is removed. Or, again, 
papules may first appear; these may remain as such through- 
out their course, or may pass into other lesions, or they may be 
associated sooner or later with vesicles. There is no other 
disease of the skin in which the lesions undergo such sudden and 
manifold changes, and every variety may manifest itself in turn 
upon the same individual. 

More or less itching is almost always present in eczema. It may 
vary in degree from the merest titillation to unendurable torture. 
Sometimes burning takes the place of itching; at other times 
they occur together. 

Eczema may be acute, running its course in a few weeks and 
then permanently disappearing, or it may be chronic and con- 
tinuous, or recurring through years. It may occur in small 
patches, single or multiple, or more rarely covering extensive 
surfaces. Unless very extensive it is not ushered in by consti- 
tutional symptoms. 

The varieties of eczema are named according to the lesions 
which the disease assumes at its beginning. These are as fol- 
lows: 

Eczema Erythematosum. This form shows itself in typical 
cases, first as an undefined erythematous state of the skin, occur- 
ring in small or large patches without discharge or moisture. 
Commonly the patch, which is sometimes slightly infiltrated, is 
covered with fine, thin scales of epidermis, and now and then the 
surface is slightly excoriated. The skin may be bright or dark 
red or even violaceous. It often has a yellowish tinge. It is 
occasionally mottled. The process may affect a small surface 
or a large one; it is often better one day and worse the next, or 
it may even go away entirely only to return a little later. It is 
apt to be chronic, and the relapses are annoying and discourag- 
ing, especially in winter time. Exposure to external heat or 
cold, a heavy meal or indulgence in alcoholic drink, is apt to be 
followed by an exacerbation of the disease. Burning and itch- 



ECZEMA. 85 

ing, alone or together, are prominent symptoms. Eczema ery- 
thematosum may run its course as such, or may develop into 
eczema squamosum. Vesicles or pustules are rarely seen. 
Eczema erythematosum is most apt to occur upon the face and 
genitals. 

Eczema Vesiculosum. Vesicular eczema commonly begins 
by a feeling of heat and irritation in the part, which shows a 
diffused or punctate redness, with itching and burning, and 
small vesicles soon show themselves, either alone or grouped, or 
sometimes running together. They are soon rilled with a yel- 
lowish, gummy fluid, and then they ordinarily break or form 
a crust. Sometimes, however, the vesicles simply dry up with- 
out breaking. In more marked cases new crops of vesicles con- 
tinue to come out, and when a considerable surface is covered, 
the quantity of fluid poured out is quite large, and the under- 
clothing or dressings are saturated. When the secretion dries, 
it is very sticky and tenacious, and this is characteristic of this 
form of eczema. Typical eczema, as described, is not so com- 
mon as the more complex varieties where the lesions are multi- 
form, papules, papulo-vesicles, vesicles, pustules, and other lesions 
being found in conjunction. The two chief characteristics of 
this form of eczema, wherever found, are the itching and the 
gummy secretion, leaving a yellow stain upon the linen. Pa- 
tients are almost always struck by this feature. 

Vesicular eczema may occur in very small patches, or in quite 
extensive areas. As it shows itself in children over the face and 
scalp, it forms the eruption popularly known as milk crust, 
scalled head, tooth rash, or moist tetter. 

Eczema Pustidosum (Eczema Impetiginosum). Pustular eczema 
is very much the same in its original appearance as vesicular 
eczema, only that the lesions assume the form of pustules rather 
than of vesicles. There is usually less heat and itching. A 
strict line cannot be drawn between the two forms, for they are 
apt to run into each other, and may coexist on the same sub- 
ject and in the same patch. The scalp and face are favorite 
seats of pustular eczema, and it is apt to occur in children who 



86 



DISEASES OF THE SKIN. 




Fig. 9. — Eczema pustulosum. (Courtesy of Dr. Duhring.) 



ECZEMA. 87 

are badly nourished or who are being brought up by hand. It 
also occurs in ill-fed and scrofulous adults. The same causes 
which would bring on vesicular eczema in a tolerably healthy 
individual will arouse the pustular form in a poorly-nourished 
person. For this reason pustular eczema always calls for tonic 
and supporting treatment. 

Eczema Papillosum. Papular eczema appears in the form 
of small, round or acuminated papules, varying in size from a 
small to a large pin's head. In color the lesions are bright or 
dusky red, sometimes violaceous. They may be discrete, or 
may run together, forming large patches, and these are often 
infiltrated. Now and then they become abraded and moist, 
forming eczema rubrum. Papular eczema is apt to occur on the 
arms, trunk, and thighs, especially the flexor surfaces. It may 
involve a very small surface, or it may cover a large area of the 
body, and it is apt to be the most stubborn, troublesome, and 
annoying of all the forms of eczema. Itching is the most promi- 
nent and troublesome symptom; at times this is agonizing. 
Patients tear and gash themselves in their efforts to gain relief 
and I have seen chronic cases where the nails have been worn 
to the quick and the ends of the fingers polished by the almost 
ceaseless efforts of the patient to assuage the torment, if only 
for a moment. 

Eczema Rubrum. This must be regarded rather as a secon- 
dary condition resulting from previous morbid action, than a dis- 
tinct variety. It is a variety only in a clinical sense. It may 
result from eczema erythematosum, vesiculosum, pustulosum, 
or papulosum. In eczema rubrum the surface of the skin is 
inflamed and infiltrated, red, moist, and weeping; occasionally 
it is more or less covered with yellowish or brownish crusts, 
often completely overspreading the part. Unless artificially 
detached, these crusts may sometimes continue to adhere, the 
process of exudation meanwhile going on underneath. Under 
these circumstances the appearance of a rough, dirty, yellowish 
or brownish scale is observed, instead of the shining, red, ooz- 
ing surface. Eczema rubrum may occur upon any part of the 



DISEASES OF THE SKIN, 





Fig. io. — Eczema rubrum. (Courtesy of Dr. Duhring.) 



ECZEMA. 89 

body, although it is most commonly found upon the legs or the 
flexures of the joints, particularly the former. The swollen, 
infiltrated, violaceous, red leg of eczema rubrum, with its vari- 
cose veins, its glazed and shining or raw surface oozing serum 
at a thousand pin-head orifices, with furious itching and burning, 
is a characteristic spectacle not to be forgotten when once 
seen. 

Eczema Squamosum. Scaly eczema is an important clinical 
variety of the disease. Like E. rubrum, it follows and results 
from the erythematous, vesicular, pustular, or papular forms 
of the disease. It 'is particularly apt to succeed erythematous 
eczema. When typical, it shows itself in the form of variously 
sized and shaped reddish patches, which are dry and more or 
less scaly. The skin is always more or less infiltrated or thickened. 
Squamous eczema may be only an ephemeral stage in the evo- 
lution of the disease. More commonly, however, the term is 
applied to denote a chronic condition, which may last for a long 
time. 

Other lesions are encountered in eczema which are worthy 
of mention. These are rhagades or fissures, occurring when the 
diseased and infiltrated skin becomes cracked by flexure, as 
about the joints or at the margins of the lips or anus. Chapped 
hands, for example, are typical instances of fissured eczema. 
Sometimes eczema may assume a warty condition, and at other 
times hard, sclerosed patches may form. 

In addition to the clinical varieties of eczema above described, 
the disease may fitly be divided into varieties, according as it 
assumes the acute or chronic form. The division, which is a 
distinct one, refers not so much to the actual duration of the 
disease as to the pathologic changes which occur during its 
course. When the general inflammatory symptoms are high 
and the secondary changes insignificant, the disease may be said 
to be acute. Wlien, however, the process has settled into a 
definite course, the same lesions continually repeating them- 
selves, accompanied by secondary changes, the disease is to be 
considered chronic. 



90 DISEASES OF THE SKIN. 

Eczema is by far the commonest of all skin diseases. It at- 
tacks persons in all grades of society, and occurs at all ages and 
in both sexes. In some cases the tendency to it appears to be, 
in a certain sense, hereditary. It occurs commonly in the 
children of persons of light complexion, with fair to reddish 
hair, with a tendency to tuberculous affections. Some persons 
are so prone to eczema that the slightest provocation will bring 
on the eruption, and an attack of dyspepsia, which in another 
person would have no effect on the skin, or contact with an irrit- 
ant which in most persons would only cause a transient dermat- 
itis, is, in such individuals, a sufficient cause to produce an 
eczematous eruption. Dyspepsia and constipation are among the 
commonest predisposing causes of eczema. In certain individ- 
uals the presence of an excess of uric acid and urates in the sys- 
tem is sufficient to produce and keep up eczema. The occur- 
rence of gout and rheumatism in connection with eczema has 
often been alluded to by writers. I am inclined to think, how- 
ever, that gout is among the rarer exciting causes. Improper 
food, as to quantity and quality, acts as an exciting cause. It 
is, however, among infants and young children that this cause 
of eczema most frequently comes into play. Pregnancy and 
lactation, debility, nervous exhaustion, excessive mental or bodily 
work, dentition, vaccination, internal irritation, as of ascarides 
or taenia in the bowels, may also determine the eruption of 
eczema. 

Eczema in most of its forms cannot, strictly speaking, be 
called contagious. When a purulent discharge exists, however? 
the disease may be self-inoculated or transmitted. It cannot 
be acquired from being in contact with or handling the discharge.* 

Among the local causes of eczema, which are numerous and 
important, and which give rise to the condition known as "arti- 
ficial eczema," are certain cutaneous irritants, as croton oil, 
mercurial ointment, tincture of arnica, tincture of cantharides, 
mustard, antimonial ointment, sulphur, and turpentine. Here 

*In the light of our present knowledge this statement is perhaps too positive. 
Auto-inoculation as in eczema intertrigo may sometimes occur. 



ECZEMA. 91 

also may be mentioned the rhus venenata and toxicodendron, 
the poison oak and ivy. All these irritants, and especially the 
latter, usually at first provoke dermatitis (see Dermatitis venenata), 
yet in certain individuals and under certain circumstances 
this may pass on to true eczema. Heat and cold, excessive per- 
spiration, especially about the genitalia, and other places where 
the skin inclines to form folds, may favor the occurrence of the 
the affection, which under the latter circumstance is known 
as ezcema intertrigo. 

Eczema is of much commoner occurrence in the winter than 
in the summer. The atmosphere of January and February, 
and particularly in this latitude the cold bleak weather of March, 
seems to favor the occurrence of the disease. Many cases of 
eczema get well in summer only to recur again in winter. On the 
other hand, however, cases are occasionally encountered where 
the attack only occurs in summer time, relapsing thus year after 
year. 

Water, as in water dressings or in fomentations, or in the 
inordinate use of bathing, may be a cause of eczema. The 
custom of very frequent bathing, especially when soap is used, 
is often harmful to the skin to a considerable degree. Alkalies, 
acids, strong and harsh soaps, may give rise to chapping and 
fissuring of the skin and to eczema. Finally, among the local 
causes of eczema may be mentioned the irritation caused by the 
presence of lice and itch mites, together with the scratching to 
which they give rise.* 

The diagnosis of eczema is of great importance, especially as the 
disease shows itself in such protean forms. There are, however, 
certain features of eczema, one or more of which are present 
in every case of the affection, and these may serve to aid in the 
diagnosis. Inflammation of the skin exists in a greater or less 
degree in all cases of eczema. It is indicated by a certain thick- 
ening of the skin, which may usually be seen by the eye, and in 
most places detected by rolling a small pinched-up portion of 

*It must be kept in mind that the first result of such local irritation is, as has 
been said, properly speaking, a dermatitis and that this only goes on to an eczema 
in persons predisposed to this affection. 



92 DISEASES OF THE SKIN. 

the skin between the finger and thumb. Swelling and oedema 
exist in all acute eczemas, and often in chronic cases. The 
patch is red and congested. In most cases of eczema there has 
been more or less fluid exudation or moisture, at one stage or 
another, in the history of the disease. This is termed "weeping, " 
"discharging," or "running." The fluid may be clear, limpid, 
and yellowish, or turbid and puriform, or it may contain blood. 
This discharge is a most characteristic feature of eczema, and is 
not present in any other disease. The crusts formed by the dry- 
ing up of the discharge are characteristic. When this has been 
copious the crusts form rapidly, and in quantity so as sometimes 
to cover and mask the skin. They are yellowish, brownish, or 
greenish in color, and when removed show a moist surface be- 
neath, but no ulceration. Among the most important diagnostic 
symptoms of eczema is the subjective one of itching. It is often 
intense, being more marked than in other diseases. It is rarely 
altogether absent, though it may vary much in degree. Burn- 
ing is also a not infrequent subjective symptom, being more apt 
to be present in erythematous eczema, and often giving way to 
itching as the disease progresses. The itching of eczema often 
gives rise to an irresistible inclination to scratch, as was noted 
in speaking of the papular variety of the affection. 

The diseases with which eczema is most likely to be confounded 
are the following: 

Erysipelas sometimes resembles eczema erythematosum, espe- 
cially as it occurs upon the face. It is, however, acute ; it begins at 
a given point and creeps slowly from place to place. The inflam- 
mation is a deep one; the surface is smooth, shining, tense, and 
more or less dusky red, while deep infiltration, oedema, heat, and 
swelling exist underneath. Erysipelas is also accompanied by 
considerable fever and constitutional disturbance. There is no 
discharge from erysipelas save that from bursting bullae, which 
sometimes form during the latter stages of the disease. 

Urticaria, particularly that variety accompanied by the forma- 
tion of small, papular lesions, is occasionally mistaken for eczema 
papulosum. The irritable condition of the skin, the history of 



ECZEMA. 93 

itching and burning occurring before the appearance of the 
lesions, all characterize urticaria in contradistinction from eczema. 
If, when the edge of the finger-nail, a pin, or other sharp object 
be drawn along the skin, a raised white welt, rapidly changing 
to red, is observed, urticaria is usually present. 

Herpes zoster sometimes resembles eczema vesiculosum, but 
is distinguished from it by the arrangement of the vesicles, the 
more regular grouping of the lesions of zoster along the line of 
some well-known nerve trunk, and the ordinary occurrence of 
neuralgia in connection with the zoster eruption. 

Psoriasis is often confounded with eczema, the diseases, when 
occurring in limited patches or upon the scalp, being sometimes 
almost indistinguishable. Old, infiltrated, inflammatory patches 
are especially difficult to make out, but in psoriasis the edges 
usually terminate abruptly, while in eczema they are more apt 
to fade into the surrounding skin. The scales on eczema 
patches are thin and scanty; on the patches of psoriasis they are 
comparatively more abundant, larger, silvery, and imbricated. 
In eczema there is usually some history of moisture or weeping, 
in one stage of the disease or another; in psoriasis the process 
is always dry. The distribution of the disease, and the occur- 
rence of patches on other parts of the body, may aid in the diag- 
nosis. In doubtful cases, where only a few scattered lesions 
are presented for examination, the whole surface should be 
diligently searched over, for a single lesion in some part of the 
body may, by its typical aspect, betray the nature of the disease 
where the majority of the lesions are quite doubtful in appear- 
ance. 

Lichen ruber planus may be confounded with eczema, but the 
peculiar square shape of the lesions in lichen ruber planus, 
together with their dusky, violaceous hue, and the fact that they 
usually run a quiet, chronic course, without change, and leave 
a deep stain behind, all serve to distinguish this affection from 
eczema. 

Dermatitis exfoliativa is a very rare disease, It presents symptoms 
which resemble closely those of generalized erythematous and 



94 DISEASES OF THE SKIN. 

squamous eczema. It may be distinguished, however, by its uni- 
versal redness ; the abundance of large, thin, papery, whitish, epider- 
mic scales, which continually reproduce themselves; slight 
itching; burning heat; and, lastly, by the absence of marked 
infiltration and thickening of the skin, a symptom common in 
eczema. It undergoes but slight changes throughout its course. 

Tinea circinata is sometimes mistaken for eczema, but the 
course of the two diseases is quite different, and the microscope 
will almost invariably settle the question of diagnosis by showing 
the presence or absence of the characteristic fungus of tinea. 
Tinea tonsurans, in its milder and more chronic stages, may 
readily be mistaken for eczema; the diagnostic points will ap- 
pear in the description given of that affection. 

Sycosis, both of the hyphogenous and coccogenous varieties, 
sometimes resembles eczema of the beard. The former, how- 
ever, is scantily crusted, and when the crusts are removed, 
instead of the smooth, soft surface of eczema, a rough, dusky- 
red, mammillated surface is revealed. The loose hairs are also 
loaded with the characteristic microscopic fungus about their 
roots. Coccogenous sycosis is essentially an inflammation of 
the hair follicles, and while eczema is superficial, sycosis usually 
spares the surface and attacks the hair follicles only. 

Favus sometimes resembles eczema; but the peculiar canary- 
yellow color of the favus crusts and their mouse-like odor is 
almost unmistakable, and the microscope will quickly settle 
the question of diagnosis, for the peculiar fungus of favus is very 
abundant in the lesions of this disease. 

Scabies is very likely to be confounded with eczema, and the 
diagnosis is often difficult. This can easily be understood when 
it is considered that the eruption of scabies is, in fact, largely an 
eczemaform dermatitis. Eczema, however, does not show 
the marked preference for certain localities as the hands and 
fingers, buttocks, axillae, abdomen, mammae, nipples, and penis, 
which scabies displays. But, chiefly, the presence or absence 
of the peculiar burrow of the itch insect will decide almost infal- 
libly between the two affections. 



ECZEMA. 95 

Syphilis. Ezcema of the scalp is at times liable to be mis- 
taken for syphilis. There is a form of pustular eczema, char- 
acterized by the presence of a few scattered lesions of the scalp, 
without a sign of disease elsewhere, which it is sometimes diffi- 
cult to differentiate from the pustular syphiloderm of the scalp. 
The occurrence or absence of a history of syphilis, or of concom- 
itant syphilitic lesions in other parts of the body, and the success 
or failure of a treatment other than anti-syphilitic, will demon- 
strate whether one or the other affection is present. Occasion- 
ally fissures with abundant purulent secretion occur on the 
scalp in the course of syphilis, and this form of the eruption may 
closely resemble confluent pustular eczema. The disgusting 
odor which ordinarily accompanies the discharge from this form 
of syphilitic disease will usually, however, serve to distinguish it. 

The treatment of eczema must be both general and local. 
Constitutional remedies judiciously employed are almost always 
needful, and prove of decided benefit in the majority of cases. 
In some cases, as where the eruption is local and due to some 
external irritant or where it is exceedingly limited in extent, 
no internal measures are called for. The subject of diet must 
be carefully attended to; all articles which are difficult of diges- 
tion must be avoided, and especially salt or pickled meats, pastry, 
cabbage, cheese, and beer, or wine. The bowels should be care- 
fully regulated; dyspepsia is often the sole exciting cause of eczema 
and the physician, who desires to treat this affection in any of 
its forms with success, should be prepared to deal with dyspep- 
sia in the majority of cases. The condition of the kidneys 
should be looked into. Diuretics are frequently of value. Sa- 
line laxatives are frequently called for in the treatment of eczema, 
and mong these the following tonic aperient, to which the name 
of "Mistura ferri acida" has been given, is one of the best: 

1$. Magnesii sulphatis, o I ( 32. ) 

Fcrri sulphatis, 3j ( 1.3) 

Sodii chloridi, 5j ( 4- ) 

Acidi sulphurici dil.. f 5j ( 4- ) 

Infus. quassia?, ad f§iv. (128. ) M. 

Sig. — A tablespoonful in a tumbler of water, before breakfast. 



96 DISEASES OF THE SKIN. 

Another formula which may be prepared extemporaneously is 
the following: 

1$. Magnesii sulphat., § j (32. ) 

Ferri sulphat., gr. viij ( 0.52) 

Sodii chloridi, 5j ( 4. ) 

Acid sulphuric dil., 5j ( 4- ) 

Ext. quassiae fid., 5 j ( 4. ) 

Alcoholis, 3iv ( 5.20) 

Aquae, ad fgiv. (128. ) M. 

It is important that the full quantity of water should be taken, 
as the volume of fluid seems to influence the action of the medic- 
ine. Sometimes hot water is less unpalatable with this mix- 
ture than lukewarm or cold water. In some cases, especially 
in winter time, the proportion of magnesium sulphate must be 
increased. The laxative mineral spring waters, as the Hathorn and 
Geyser springs of Saratoga, or the Hunyadi Janos (or Arpenta), 
German mineral waters, are beneficial in many cases. I like the 
Hunyadi Janos best for most cases, and I sometimes prescribe 
it after a short course of the Mistura ferri acida, as its use can be 
kept up indefinitely without an increase of dose. In infantile 
eczema, where constipation exists, the simple unspiced syrup 
of rhubarb, in repeated small doses, alone or with magnesia, 
is often found desirable. A very good powder is the following: 

R. Hydrarg. chlor. mite, gr. vi-xij (04-0.8) 

Pulv. rhei, gr. xviij (1.2 ) 

Magnesias calcinat., 5ss. (2. ) M. 

In Chart. No. vj div. 

Sig. — One, at night. 

To make these more acceptable they may be given as com- 
pressed tablets or in capsules. 

This is for an infant six months to a year old, of average 
strength. In weakly infants the dose of calomel and rhubarb 
should be slightly reduced. The powder should be continued 
until its effect is seen. Purgation, however, should not be 
induced. A somewhat similar prescription, without the mercu- 
rial, and in a fluid form, is the following: 



ECZEMA. 97 

1$. Pulv. rhei, 

Sodii bicarb., aa 5j-iij ( 4.-12.) 

Aquae men th. pip., foiv. (128. ) M. 

Sig. — A teaspoonful, after meals. 

This dose is given thrice daily. 



Elliott uses the following for young babies: 



I}. Hydrarg. chlor. mite, gr. T fo (0.0065) 

Ol. ricini, 

Mist, cretae, 

Aquae, aa rr|xv. (1.) M. 

This dose is given thrice daily. 



In adults, especially when the eczema is acute, and occurs in 
a robust individual, the laxative treatment is best introduced by 
a brisk mercurial purgative. Especially is this the case when 
the patient is suffering from constipation when first seen. Here 
the bowels are to be thoroughly unloaded, to begin with, and 
then we may enter upon the more direct treatment of the dis- 
ease. It is wonderful to see what a good effect two or three 
compound cathartic pills, or six grains (0.39) of blue mass, 
given the evening before the administration of Mistura ferri 
acida, will have on the patient's comfort, external and internal. 
Afterward let the case be treated internally, on general medical 
principles, and let cathartics and laxatives be given or withheld, 
as the patient's condition suggests. In old persons, particularly 
when the patient has been a high liver or is rheumatic, or in 
those unusual cases where a gouty element may exist, diuretics 
and alkalies are indicated. In such conditions the following 
prescription was recommended by the late Tilbury Fox: 

1$. Magnesii sulphat, 5iv ( 16. ) 

Magnesii carbonat., 5j ( 4. ) 

Tinct. colchici., rrjxxxvj ( 2. ) 

Ol. menth. pip., rqij ( 0.13) 

Aquae, fovij. (224. ) M. 

Sig. — Two tablespoonfuls in a wineglass of water, every three or four 
hours. 
7 



98 DISEASES OF THE SKIN. 

The following formula, suggested by Hardaway, has been 
found useful : 

~fy. Ol. morrhuae, fgiv (128.) 

Pancreatin saccharat., 3j ( 4-) 

Pulv. acaciae, q. s. 

Glyceriti hypophosphiti, 
Syr. calcis lactophosphatis, 

Aquae, aa f§iv (128.) 

Ol. gaultheriae, gtt. xxx. ( 2.) M. 

Ft. Emulsio. 

Sig. — Tablespoonful three times a day, after meals. 

The acetate and carbonate of potassium in full doses, and 
also the alkaline mineral waters, may be employed. In persons 
of debilitated constitution or in scrofulous persons, particularly 
in the badly-nourished children of tuberculous parents, cod- 
liver oil is demanded, and iron in various forms is to be recom- 
mended in some cases. The following prescription is one which 
I often employ with satisfaction: 

B. Tinct. ferri chlor., 

Acidi phosphorici dil., aa f§ j ( 32.) 

Syrupi limonis, ad foiv. (128.) M. 

Sig. — A teaspoonful in a wineglass of water, after meals. 

Syrup of the iodide of iron and wine of iron are also eligible 
preparations, particularly for children. Quinine and strychnia 
are sometimes called for by the general condition of the patient. 
Arsenic is useful in a limited class of cases, more especially in 
anemic cases where it acts as a tonic simply and not in any way 
as a specific. In former times the use of arsenic in eczema 
of all grades and varieties was much abused, and even now it 
too often forms a part of that routine treatment which is the refuge 
of ignorance. Frequently, so far from doing good, it does harm 
by upsetting the stomach, and its effect seems to be particularly 
pernicious in some acute and inflammatory forms of the disease. 
Tar has been used in some chronic cases internally, with benefit. 
Sulphur-spring waters are also used occasionally. 



ECZEMA. 99 

Regarding the local treatment of eczema, ordinary water 
may be employed for washing purposes, in most cases; when 
the skin is delicate and sensitive, distilled water or water made 
milky by the addition of some bran or starch. It is generally 
better to use water which has recently been boiled when this is 
practicable. A very good method of softening the water, par- 
ticularly where it is to be applied to the face, is to take a hand- 
ful of bran, sew it up in a small linen bag, and squeeze the bag, 
like a sponge, through a basin of water until the water is quite 
milky. This gives a soft and agreeable quality to the water when 
it is applied to the skin. The water may be used cold or warm, 
as best suits the feelings or fancy of the patient; but the most 
important point is not to use too much of it or too often. The 
best rule for the use of water in eczema is to use it as sparingly 
as possible. The only two indications for its employment are, 
either the removal of crusts or the cleansing from absolute and 
unendurable assoilment; water sometimes seems to act upon the 
eczematous skin almost like poison. White castile soap is ordin- 
arily the only soap necessary to cleanse the skin of crusts and 
scales, but the superfatted soaps now put extensively upon the 
market are preferable in acutely inflammatory conditions. 
Occasionally the stronger potash soaps, mus tbe brought into use. 
Sometimes the "spiritus saponis kalinus" the formula of which 
is given below may be used instead of the solid soaps. Whatever 
soap is employed, it should always subsequently be completely 
washed off the skin, unless a distinctly macerating or caustic 
effect is desired, or, occasionally, when the medicinal effect of 
some contained ingredient is desired. 

The local treatment of eczema is of great importance; many 
cases can be cured by outward applications alone, and there 
are very few where these can be dispensed with entirely. 
Before instituting local treatment, the part affected should be 
examined, with the view of determining whether the disease 
is acute or chronic, and what the characteristic lesions, the 
amount of heat, redness, swelling, etc.; and also the condition 
of the epidermis, whether intact or torn and abraded. It is 



IOO DISEASES OF THE SKIN. 

most important, also, to take into consideration the area involved, 
whether this be great or small, for not only must we be on our guard 
not to use irritant remedies, but it must be remembered also that 
some applications are poisonous by absorption, when applied 
over large raw surfaces. 

In most cases of eczema there are certain secondary products, 
crusts, scales, and extraneous matter, which must be removed 
before the local remedies can be advantageously applied. Some- 
times it is difficult to get patients to remove these extraneous 
matters; a feeble attempt is made, giving rise, perhaps, to pain 
or slight bleeding, and the statement is offered that the "scab" 
cannot be gotten off. The mass of rancid grease, decomposing 
pus, serum, and sebaceous matters, mingled with epithelial 
debris, make a very poor covering, however, for an abrasion or 
ulcer which is to be healed, or to which local treatment is to be 
applied successfully. The physician should give the most pre- 
cise directions as to the method of removing the crusts or, better, 
should, when practicable, remove them himself. Soap and water 
alone will not do this. Poultices made with hot almond oil 
and rendered aseptic, or at least sprinkled with boric acid, 
applied to the crusts after these have been themselves thoroughly 
saturated with the oil, will often suffice. At other times, compresses 
wrung out of hot water and covered with oiled silk will do better, 
occasionally solution of hydrogen peroxide may be employed. 
Frequently a strong solution of carbonate of sodium, also applied 
on compresses, will soften crusts more rapidly than anything 
else. Sapo viridis spread on lint, like ointment, laid on the 
skin and covered with waxed paper or oiled silk, will soften 
the most stubborn crusts. Crusts in the scalp sometimes cling 
stubbornly, on account of the numerous hairs running through 
them. By lifting the edge gradually and cutting away the hairs 
from underneath, the crust can be lifted expeditiously and with- 
out pain. I dwell on this little point because I have so often 
seen well-directed treatment fail of its intention, because the way 
had not been prepared for the local remedies. 

Two general principles may be mentioned with regard to the 



ECZEMA. IOI 

local treatment of eczema. These are, first, that in the acute 
form the treatment can scarcely be too soothing; secondly, that 
in the chronic form the treatment can hardly be too stimulating. 
Of course, these general principles must be modified somewhat, 
according to individual circumstances, especially with regard to 
the latter. 

Acute Eczema. When a remedy is to be applied for the first 
time to a case of acute eczema, it is usually better to use it over 
a limited area until its effect is perceived, for it must be borne in 
mind that a remedy which has been of service in one case will 
not necessarily suit another, even when the general features of 
the disease are the same. If one remedy does not suit, another 
must be tried, for it is often difficult to decide beforehand what 
application will be most useful. The indication is to give ease 
to the patient, and medicaments must be changed, if necessary, 
until this end is attained. 

Starch powder is best for large surfaces at first; the parts may 
then be covered with muslin or soft linen. Lycopodium, sub- 
nitrate of bismuth, dermatol, talc, or similar indifferent or anti- 
septic powders, alone or associated, may be employed on isolated 
patches. 

The starch poultice is one of the most important moist applic- 
ations. Potato starch is preferable. It should be mixed with 
5 to 10 parts of boric acid per iooo, and then placed in a flat 
bag, dipped in boiling water, and allowed to cool before applying. 
In some cases the starch may be applied as a paste, and then 
covered with very fine soft linen and- carefully fastened in place 
with bandages. 

No form of treatment gives more relief in acute eczema than 
this if carefully applied and changed every three or, at most, six 
hours. In less severe cases, or in later stages of the disease, 
these moist applications may be made by covering the affected 
part with two or three turns of soft linen or muslin, impregnated 
with decoction of bran or starch water, and covered with thin, 
impermeable cloths. The linen dressings should be made 
aseptic before each application; care should be taken to 



102 DISEASES OF THE SKIN. 

avoid creases and folds. If the patient is cold or afraid of be- 
ing cold, cotton or flannel may be applied over all. In severe 
cases impermeable cloths may be applied directly to the skin, 
but these should be of the finest tissue, and not of thick rubber 
cloth which is sometimes employed to the injury of the patient. 

All these modes of treatment represent in reality the con- 
tinuous bath; their action, in certain cases, is most favorable, 
both in giving relief to the patient and in curing the disease. 
Careful attention to detail is, however, absolutely necessary. 

In some severe cases of acute eczema benefit is obtained from 
oleaginous preparations. These should be made with sterilized 
oil, alone or with the addition of a small quantity of laudanum, 
bi-carbonate of sodium, boric acid, etc. The method of applic- 
ation is similar to that described above, and is to be employed 
with the same precautions. 

In acute vesicular or erythematous eczema water used in 
ablution is, as a rule, injurious, and irritates the skin. It should 
never be employed, except in cases of extreme necessity, for the 
absolute requirements of cleanliness. In the place of washing, 
the affected part may be powdered, from time to time, with a 
dusting powder, such as the following, known as "McCall An- 
derson's powder:" 

1$. Pulvis camphorae, 5ss (2.) 

Pulvis zinci oxidi, oiss ( 6.) 

Pulvis amyli, 5vj- (24.) M. 

The following plan of treating acute vesicular eczema is that of 
Dr. James C. White, of Boston, which I have used in hundreds of 
cases with great satisfaction. I consider it one of the best forms 
of treatment for the majority of cases in the early acute stages of 
eczema. The affected part is to be bathed with lotto nigra ("black 
wash"). This is used either in full strength, or else diluted 
with an equal part of lime-water, and sopped on the surface by 
means of a rag or mop, or applied by means of cloths saturated 
with the wash and allowed to remain on the surface. As a sub- 
stitute for the ordinary wash, the following, nearly the same in 



ECZEMA. 103 

character, may be used, especially on the face, as it clings better 
to the skin: 

fy. Hydrarg. chlor. mite, 5ss ( 2.) 

Mucilago tragacanthae, 5j ( 32.) 

Liquoris calcis, ad 5 x jj- (384.) M. 

1$. Hydrarg. chlor. mite, oss ( 2.) 

Liq. calcis, f§xjj. (360.) M. 

After the wash has been applied for some minutes, oxide of 
zinc ointment, or in winter the following: 

1$. Pulv. zinci oxidi, gr. lxxx ( 5.20) 

Ung. aquae rosae, 

Petrolati, aa oiv. (16. ) M. 

is applied gently with the finger, before the surface has had time 
to dry; and this treatment is repeated at intervals of a few 
hours. Sometimes ''Lassar's paste" may be substituted for this. 
It is composed as follows : 

1$. Zinci oxide. 

Amyli aa oii ( S.) 

Petrolati oiv (16.) 

As a rule the itching and burning is relieved at once, and occa- 
sionally the disease is arrested in its course. Sometimes the 
black wash may be applied every half hour or hour, the ointment 
being laid on at longer intervals. 

When there is a good deal of inflammatory action, and when 
the skin is thickened and more or less doughy and cedematous, 
bread poultices, made of bread crumb mixed with ice-cold lead- 
water may be employed. The sedative effect of this application 
is extremely soothing and grateful. The following lotion is 
highly recommended in some cases: 



1$. Pulv. zinc. carb. pnecip., §i (32 

Pulv. zinci oxidi, oss ( 16 

Glycerini, 5ij ( 8 

Aquae, fgvj. (192 



.) M. 

It should be applied frequently, by means of a bit of rag or a 
rag mop, the sediment being allowed to remain on the surface. 



104 DISEASES OF THE SKIN. 

Another very good remedy, in my experience, and one par- 
ticularly adapted to the treatment of eczema covering a consider- 
able surface, is the following: 

1$. Ext. grindeliae robustae, fid.,. . f§ss ad f5ij (16.-64.) 

Aquae, Oj. ( 512.) M. 

This is preferably applied on cloths, which are permitted to 
remain in contact with the surface until nearly or quite dry, 
before removal. A lotion of sulphate of zinc, fifteen to thirty 
grains (1-2) to the pint (512.) of water, acts admirably in some 
cases, especially in eczema about the hands. When itching is a 
severe and prominent symptom, applications of hot water, or of 
cloths wrung out of the same and applied in quick succession, 
as hot as may be borne, to the affected side, often allay this 
exasperating symptom when all else has failed. Carbolic acid, 
which is one of the most efficient anti-pruritics, can rarely be 
employed in the acute stages of eczema, but now and then, when 
burning is less prominent as a symptom, and when itching is 
most tormenting, it is of use. It may be combined with black 
wash, as thus: 

ly. Acidi carbolici, 5ij— iv (8. -16.) 

Glycerins, foj ( 32 ) 

Lotio nigrae, Oj. (512. ) M. 

The erythematous form of eczema, when the skin is yet 
unbroken, and when there is at the same time more or less 
inflammatory infiltration, is that in which carbolic acid is likely 
to agree. It must be applied with caution, however, in the acute 
stage of eczema, until it is found to agree with the individual 
case under treatment. 

While, as a general thing, ointments are not found to agree 
in acute eczema, yet in a certain number of cases these prepara- 
tions appear to suit better than lotions. The oxide of zinc oint- 
ment, the hard-ridden and universal remedy for skin diseases, 
here finds its legitimate sphere. Bulkley recommends that in- 
stead of being made with lard it should be made with cold cream, 
and should contain sixty instead of eighty grains of the oxide of 



ECZEMA. I05 

zinc to the ounce. Both of these changes are, improvements. The 
oxide of zinc ointment, as dispensed, is too thick and almost 
tough, especially for winter use in this climate. So, for conveni- 
ence sake, it may be presoribed mixed with an equal weight of 
vaseline or cosmoline. It should not be benzoated, or if benzoin 
is used it should be used in small quantity. The unguentum 
aquae rosae is a much better base for all or almost all oint- 
ments than lard or vaseline. The lard is apt to turn rancid, 
wiiile the vaseline is too thin for ordinary use, although preferable, 
on this account, for use in the hairy parts. 

Oleate of zinc enters into the composition of a number of 
ointments which are of value in the treatment of acute eczema. 
It is made as follows: Take one part of oxide of zinc and eight 
parts of oleic acid; stir together; allow to stand two hours; 
heat until dissolved. On cooling, a yellowish- white, hard mass 
results, which may be variously made into ointments. The fol- 
lowing is one formula : 

II. Zinci oleat., 

Olei olivse, aa 5iv. (16.) M. 

Or it may be made up with cold cream: 

lk. Zinci oleat., 

Ung. aqiue rosae, aa oiv (16.) 

Olei amygdala?, q. s. M. 

Oleate of bismuth acts in very much the same manner. The 
following formula, brought into notice by Dr. McCaU Anderson, 
is an elegant preparation when prepared with due pharmaceu- 
tical skill : 

"McCall Anderson's Ointment." 

]$. Bismuthi oxidi, 5 j 

Acidi oleici, 5 j 

Cerae albae, oiij 

Yaselini, 5ix 

01. rosas, rr^ij. 

* Rub up the oxide of bismuth with the oleic acid, and let it stand for two 
hours; then place in a water-bath until the bismuth oxide is dissolved; add the 
vaseline and wax, and stir till cold. 



( 4. 


) 




(32. 


) 




(12. 


) 




(36. 


) 




( . 


[2) 


M.* 



106 DISEASES OF THE SKIN. 

Subnitrate of bismuth is a very agreeable and slightly astrin- 
gent as well as sedative remedy, when used in the form of oint- 
ment. 

The following — 

1$. Pulv. bismuth subnitrat., 3ss-3 j (2.-4.) 

Ung. aquae rosae, §j. ( 32.) M. 

is an excellent application in acute eczema of the scalp, par- 
ticularly in children. 

Diachylon ointment, made according to the formula of Hebra, 
with due care, and by a skilled pharmaceutist, is most grateful 
and soothing to the inflamed skin. It is composed as follows: 

1$. Olei olivae opt., f §xv ( 480.) 

Pulv. Kthargyri, Siij— ovj ( 120.) 

Aquse, q. s. 

Coque. Fiat unguent.* 

Diachylon ointment is usually more effective when spread 
upon cloths than when rubbed in with the finger and, in fact, the 
same may be said of all ointments applied with a view to their 
soothing effect. The patient should be directed to cut out bits of 
linen cloth to fit the part to be covered, and then to spread the soft 
ointment upon these as thick as butter upon bread. When 
applied, they should be covered with oiled silk or waxed paper, 
for cleanliness sake. 

Among other soothing dressings may be mentioned finally, cold 
cream of cucumber ointment, glycerole of starch, almond and 

*The following directions are taken from Duhring: "The oil is to be mixed 
with a pint of water and heated, by means of a steam bath, to boiling, the finely- 
powdered litharge being sifted in and stirred continually; the boiling is to be 
kept up until the minute particles of litharge have entirely disappeared. During 
the cooking process a few more ounces of water are to be added, from time to 
time, so that, when completed, water still remains in the vessel. The mixture is 
to be stirred until cool. The ointment is difficult to prepare and requires skill- 
ful manipulation. When properly made it should be of a light yellowish-gray 
color, and of the consistency of butter. To ensure a good article it is essential 
that the very best olive oil and the finest litharge be employed." 

The physician should examine each lot as made up, when this is possible, and 
he should in all cases decline to employ any ointment which has been on hand 
over a week. Although one of the most perfectly soothing and sedative of all 
ointments, unguentum diachylon is probably more apt to be ill-made or decom- 
posed when dispensed, than any other. 



ECZEMA. 107 

olive oils, and dilute glycerine. The olive oil must be pure 
and of good quality; the cotton seed oil often supplied in its 
place is irritating. While glycerine in full strength disagrees 
with many skins, yet, where diluted with one to three parts of 
water, it will usually be found to agree. 

In papular eczema, the eruption being more discrete and 
scattered, the applications to be made must differ somewhat in 
form from those employed in vesicular eczema. Lotions are 
usually preferable, and, in many cases, where the individual 
lesions are widely separated, these alone are admissible. Then, 
too, the inflammation is of a different character, and pursues, 
as a rule, a more chronic course. Soothing applications, there- 
fore, do not often come into use, and we are more apt to have 
recourse to stimulant remedies, as the so-called anti-pruritics, 
and chiefly tar and its derivatives. Carbolic acid is the most 
important and generally useful of these remedies, and the one 
most apt to do good in papular eczema. 

A further account of the treatment to be employed in acute 
eczema will be found under the head of the treatment of eczema 
attacking particular regions of the body. 

Chronic Eczema. In some cases the treatment employed 
in the acute stage of eczema may also be made use of in the 
chronic condition of the affection; more frequently, however, other 
and more stimulating remedies will be found more serviceable. 

Carbolic acid may be employed, either in the form of a lotion, or 
as an ointment, of the strength of five to twenty grains (0.32-1.30) 
to the ounce (32.) of oxide of zinc ointment, benzoated lard or vase- 
line. It may be relied upon as an anti-pruritic remedy when all 
others fail, and is a most valuable application in chronic eczema. 
Tar and its preparations come largely into use in the treatment of 
chronic eczema. The tarry preparations must be handled with 
care, however, for, if used injudiciously, or in too great strength, 
they are apt to inflame the skin and retard the process of cure. 
They are most apt to be useful when the disease has completely 
reached the chronic stage, and when there is more or less infiltra- 
tion. In using tar in the form of ointment, which is ordinarily 



Io8 DISEASES OF THE SKIN. 

the most convenient form of employing this remedy, its strength 
should at first rarely exceed one to two drachms (4.-8.) to the ounce 
(32.). It can be increased later, if the skin requires and will bear in- 
creased stimulation. The two forms of tar commonly employed are 
the pix liquida of the Pharmacopoeia and the oleum cadini. Their 
effect upon the skin is apparently identical. A very convenient 
formula is the following: 

1$. Ol. cadini, ' 5ss ( 2.) 

Ung. aquae rosae, 5 j. (32.) M. 

On the scalp, fluid or semi-fluid preparations are usually 
more convenient than ointments ; the following formula is recom- 
mended by Duhring: 

1$. Picis liquidae, 5 j (4-) 

Glycerinae, f 3 j ( 4-) 

Alcoholis, f3vj (24.) 

Ol. amygdalae amaras, ln \ xv ( O M. 

The oil of cade mixed with three or four parts of alcohol or of oil 
of almonds, may be used as an application in some forms of 
eczema of the scalp. These preparations are not to be smeared 
on the surface, or applied on cloths, as the soothing remedies. 
Much of their efhcacy depends upon their proper and thorough 
application; they must be worked into the skin, in order to pro- 
duce their full effect; patients and attendants should be especially 
instructed on this point. In thick old patches of chronic disease, 
the following preparation may be thoroughly rubbed in by means 
of a little mop of cotton fastened to the end of a stick : 

1$. Picis liquidae, 
Saponis viridis, 
Alcoholis, aa 3ij. (8.) M. 

This preparation is known under the name of "tinctura 
saponis cum pice." To produce a stronger impression, caustic 
potash may be used instead of the soap, in the proportion of five 
to fifteen grains to each ounce of the mixture. The following 



ECZEMA. I09 

preparation, known as ''liquor picis alkalinus, " was introduced 
to the notice of the profession by Dr. Bulkley: 

1$. Picis liquidae, 5ij (8.) 

Potassae causticae, 5 j (4-) 

Aquae, f 5v. (20.) M. 

The potash is to be dissolved in the water, and gradually 
added to the tar, while rubbing in a mortar. Of course, this 
preparation is much too strong to be used undiluted, excepting 
in the rarest cases. As a lotion, it may be diluted with from eight 
or more parts of water at first, down to two parts after a little 
trial; care should be taken not to make the lotion too strong at 
first. The liquor picis alkalinus may also be combined with 
ointment, from one to two drachms to the ounce. In some 
cases of chronic eczema with much thickening Hebra's modi- 
fication of Wilkinson's ointment may be used: 

1$. Flor. sulphuris, 

Ol. cadini, aa oiv (16.) 

Sap. viridis, 

Adipis aa 5 i (32.) 

Crctae preparat., oiiss. (10.) M. 

Soaps play an important part in the treatment of chronic 
eczema. Strong alkaline soaps are used in eczema for their 
remedial effect, being particularly employed when some in- 
filtration is to be removed, or when a stubborn and rebellious 
local patch of disease requires strong stimulation. Of these, 
the most generally useful is that known as "Hebra's soap," 
"green soap," or, as it has been called in other parts of this 
work, "sapo viridis," a strongly alkaline potash soap. It may 
be employed alone or in the form of an alcoholic solution, known 
as "spiritus saponis kalinus:" 

1$. Saponis viridis, oij (64.) 

Alcoholis, f5j. (32.) M. 

Dissolve with the aid of heat, and filter. 

It may be scented with lavender or other perfume if desired. 



IIO DISEASES OF THE SKIN. 

This wash is very useful also for cleansing patches of eczema 
when covered with accumulated crusts and scales. 

Under ordinary circumstances, and unless left in contact with 
the skin with a particular object in view, these stronger soaps, 
should be washed off at once, and some oleaginous or fatty sub- 
stance applied. Much mischief is sometimes done by allowing 
caustic soaps to remain in contact with the skin. 

Sapo viridis is particularly useful in extensive infiltrated eczema 
rubrum of the leg and other parts. It should be well rubbed 
into the affected patches, by means of a flannel rag, until con- 
siderable smarting, abundant serous discharge, and, perhaps, 
slight bleeding are induced. The soap is then to be completely 
washed off with pure hot water, the patch of disease lightly dried 
with a soft cloth, and some soothing ointment, applied, spread upon 
strips of cloth. This process is repeated once, or sometimes twice, 
daily, and when it can be properly carried out is a rapid and 
efficient method of dealing with this form of eczema. In old, 
infiltrated patches of eczema, and in eczema of the palms partic- 
ularly, solutions of caustic potash, ten to forty grains (0.60-240.), or 
even a drachm (4.), to the ounce (32.), may be employed to advant- 
age. The stronger of these must be used by the physician himself, 
and should not be entrusted to the patient or to his attendants. 
The application should be made with a little mop tied to a stick, or 
occasionally with a bit of wood. The parts should be immedi- 
ately bathed with cold water, or covered with cold-water compresses, 
and after a short time a soothing ointment may be applied. This 
procedure reduces infiltration and stops itching very effectually. 
Pushed too far, there is danger of causing local sloughing, with 
subsequent scars. It should not be used more than once or 
twice a week under ordinary circumstances. 

Other remedies for the chronic forms and stages of eczema 
may be mentioned, as follows: Mercurial preparations are 
particularly valuable, especially when the disease is confined 
to a small area. When covering a considerable surface, mer- 
curials should be used with care, or not at all, both on account of 
the possibility of overstimulation and for fear of absorption 



ECZEMA. Ill 

with resultant salivation. Calomel is the most generally useful 
of mercurial preparations; it may be employed according to 
the following formula : 

J$. Hydrarg. chloridi miti, gr. x-xxx (0.65-2.) 

Ung. zinci oxidi, 

Petrolati, aa §ss. ( 16. ) M. 

The red oxide of mercury in ointment of the strength of five 
to thirty grains to the ounce, is also often very useful. Some- 
what milder is the ointment of ammoniated mercury, which may 
be employed in somewhat less proportionate strength to advant- 
age in the pustular eczemas of children. Sulphur is also a highly 
useful application in some forms of eczema, particularly when 
there is a moist surface, or when its 4 1 cornif ying " influence is 
required to regenerate the horny epithelium of the skin. It may 
be used in the form of ointment of the strength of one to two 
drachms to the ounce of cold cream, in chronic eczema rubrum, 
occurring in patches; also, occasionally, in chronic pustular ec- 
zema, particularly about the hands. It should usually be used 
in a mild strength at first, and after a few days' use should gen- 
erally be substituted, for a time at least, by some other prepara- 
tion. A combination of tar and sulphur ointments sometimes 
acts happily in old chronic eczemas with much itching and infil- 
tration. Boric and salicylic acids have been highly recommended 
by authors of repute during the past few years. "Lassar's 
paste," given above, is a very excellent preparation for use in 
hot weather. In winter it is a little stiff, and I think the 
proportion of starch might conveniently be reduced for cold 
weather. 

Some dermatologists employ gelatines in these forms of eczema. 
Two common formulae are as follows : 

Pick's gelatine: — 

1$. Gelatin., §iss ( 48.) 

P. zinci oxidi, oj ( 32.) 

Glyceringe, §ij-3viss ( 90.) 

Aquae, oiij-ovj. (120.) 

Gradually heat the ingredients as above until thoroughly incorporated. 



112 DISEASES OF THE SKIN. 

Jameson's gelatine: — 

Gelatin., giss ( 48.) 

P. zinci oxidi, 5j ( 32.) 

Adipis, 5j ( 32.) 

Glycerinse, Sviss. (208.) 

These are heated together over a water-bath, and two per cent, salicylic 
acid added. 

The gelatines are melted at a low temperature and applied 
with a brush. They have the advantage of neatness and occlu- 
sion, and save the use of bandages. They are somewhat incon- 
venient in application, though they may be of advantage in hos- 
pital and dispensary practice. 

Another formula frequently employed is "Ihle's ointment:" 

1$. Resorcin, gr. x (0.6) 

Lanolin, 

Vaselin, 

Pulv. zinci oxidi, 

Pulv. amyli, aa 3ij- ( 8.) M. 

Some years ago Mr. Squire, of London, brought forward the 
preparation known as glycerole of the subacetate of lead as a 
remedy in chronic eczema. His formula is as follows : Acetate 
of lead, 5 parts; litharge, 3 \ parts; glycerine, 20 parts, by weight. 
Mix and expose to a temperature of 350 F., and filter through 
a hot water funnel. The clear viscid fluid resultant contains 
129 grains of the subacetate of lead to the ounce (5.26 gm. to 
30 gm.). This is used as a stock, from which the preparations 
employed are made by dilution with simple glycerine. This 
preparation may be used in the treatment of chronic eczema 
rubrum of the leg, particularly when the disease is extensive, of a 
dusky red hue, accompanied by weeping, oedema, and a varicose 
condition of the veins. Also in eczema of the palms and soles. 
In eczema of the leg the glycerole stock may be used diluted 
with three parts of pure glycerine. Strips of linen soaked in 
this preparation are applied to the affected limb and covered 
with wax paper and a bandage, the dressing being changed 
once or sometimes twice daily. This method of treatment may 
be employed to advantage in many cases when the treatment by 



ECZEMA. 113 

means of sapo viridis and unguentum diachyli cannot be carried 
out. In eczema of the palms and soles the following ointment 
gives good results: 

1$. Glycerol, plumbi subacetatis, f 5ss (2.) 

Glycerinae f 5iss (6.) 

Ung. aquae rosae, 3j (4.) 

Cerae albae, q. s. M. 

This is to be made into a tolerably firm ointment, and applied 
to the affected parts. It is better to precede its use with the 
application of solutions of caustic potash, and it should be spread 
thickly upon narrow strips of linen, and placed in close apposi- 
tion to the affected parts, being covered with wax paper to pre- 
vent soiling. 

For obstinate, circumscribed patches of eczema, blistering 
with cantharidal collodion will sometimes be found beneficial.* 

With the same object, strong solutions of carbolic acid in 
alcohol, tincture of iodine, and solutions of nitrate of silver, 
or even the solid stick, may be employed. Vulcanized india 
rubber has been used extensively in the treatment of eczema, 
and may be employed with advantage, both as a protective 
against atmospheric influences, as a preparative for other 
applications, and as a direct therapeutic agent. Rubber cloth 
in sheets, rubber masks and finger-stalls, are also often employed 
in the various forms of eczema with advantage. In severe or ex- 
treme cases of eczema, furuncles often occur as a sequel, due to 
the implantation of the staphylococcus pyogenes by scratching 
and rubbing at a time when the system is impaired. To prevent 
the occurrence of these furuncles, some parasiticide, as thymol, 
carbolic acid, resorcin, or sulphur, should be added to whatever 
ointment is employed toward the end of the treatment. Unna 
thinks that the addition of one or two parts of corrosive sublimate 
per thousand of oxide of zinc ointment is the surest preventive 
of post-eczematous furunculosis. 

* Of the late Rontgen ray or X-ray has been used to advantage in the treatment 
of chronic and rebellious patches of eczema. So far as I have had experience 
with this plan of treatment I have found it of value when all other means have 
failed. (See Pusey and Caldwell, "The Practical Application of the Rontgen 
Rays, etc.," Phila., 1905.) 
8 



114 DISEASES OF THE SKIN. 

Having now spoken of the acute and chronic forms of eczema 
in general, it will be advantageous to next consider this disease 
as it is met with in different localities. 

Universal eczema is very rare; when it does occur it is usu- 
ally erythematous or squamous. Its history in these cases will 
serve to bring out one or another of the points mentioned in 
discussing the general diagnosis of the disease, and so lead to 
its identification. 

Eczema oj the Scalp. This is usually erythmatous, vesicular, 
or pustular. The first variety rapidly runs into the squamous, 
the scalp being more or less covered with red, scaly patches, 
which are very itchy. The pustular variety is common among 
children. The pustules commonly come out in great numbers 
about the hair follicles. They soon rupture, and the liquid, 
oozing over the skin, forms yellowish-green crusts, sometimes 
amounting to thick masses. The hair becomes matted and 
caked; the scalp, if not cleansed, gives out a very offensive odor; 
and the disease, unless checked by proper treatment, may. last 
from a few weeks even to years. The itching is usually not so 
decided in this as in other forms of eczema. Sympathetic enlarge- 
ment of the lympathic glands about the back of the neck and 
behind the ear is common and, in the case of children, often 
gives rise- to great anxiety on the part of parents. The glands 
never suppurate, and the patient's friends may be assured, with 
confidence, that, as the irritation and inflammation about the 
scalp subside, the glandular engorgement will spontaneously 
disappear. Small abscesses often complicate eczema of the 
scalp in unhealthy children. Pediculi also are very frequently 
present, and the scalp should be examined for the insects or their 
nits in all cases of supposed pustular eczema, because, in reality, 
the affection may be a dermatitis superinduced by the irritation 
of the pediculus capitis. A patch of pustular eczema occurring 
in the occipital region, especially in neglected and ill-nourished 
children, almost invariably points to the presence of pediculi 
as a cause. When present, they should at once be removed 
by the means described under Pediculosis capitis. 



ECZEMA. 115 

Eczema of the scalp may be confounded with psoriasis, sebor- 
rhcea, favus, syphilis, and tinea tonsurans. From psoriasis of 
the head eczema may be distinguished by the symptoms men- 
tioned in the general diagnosis of the disease. Seborrhceic eczema 
sometimes resembles ordinary eczema capitis very closely, but the 
pearly color of the scales and the not unfrequent combination 
of more or less seborrhcea with the eczema, making the scales 
greasy, as also its diffusion, and the history of the case, are 
important elements in distinguishing the two forms of the disease.* 
Other points have been touched upon above. Pustular eczema 
alone is likely to be mistaken for favus, but the mustard or canary 
color of the favus crusts, their commonly cup-shaped outline, 
and the dry, pulverulent consistence of the masses of fungus, 
together with the microscopic appearance, will be sufficient to 
distinguish it from eczema. As before mentioned, certain 
syphilitic diseases of the scalp may be mistaken for eczema. 
The history of the case, with the characteristic symptoms above 
given, are ordinarily sufficiently distinctive. Erythematous 
or squamous eczema may sometimes be mistaken for tinea ton- 
surans. The patches of eczema, however, are not attended with 
loss of hair. In ring-worm of the scalp the hairs are broken 
off uniformly about an eighth or a quarter of an inch beyond 
the scalp. The hair has a nibbled appearance. The patches 
in ring- worm are apt to be roundish in outline. In eczema they 
are irregular. The color of the scalp is of a leaden hue, while 
in eczema it is reddish, and has more the appearance of inflam- 
mation. The itching in eczema is marked. In tinea tonsurans 
it is slight. A history of contagion is frequently found in con- 
nection with tinea tonsurans. 

The treatment of eczema capitis will, of course, depend upon 
the variety and stage of the affection in each case. In pustular 
eczema the crusts must first be removed by means of hot water 
and soap, preceded, if necessary, by thorough saturation with 
olive or almond oil, to soften and loosen the crusts. Some- 
times the scalp must be well saturated with oil and covered with 

* See Eczema seborrhceicum. 



Il6 DISEASES OF THE SKIN. 

a cap over night; and perhaps the process must be repeated; 
at all events, the crusts must be removed before any applications 
are made. Occasionally the oil alone appears to exert a cura- 
tive influence, but usually more decided treatment is required. 
The hair in children, boys, and men may be cut short, especially 
when lice are present. In women this sacrifice is not necessary, 
and should not be permitted. Now and then, however, we 
meet cases where women are suffering with severe and neglected 
eczema due to pediculosis of long standing, and where the hairs 
are so matted and glued together that we are obliged to have 
recourse to the scissors. 

As to medicinal applications: in inflammatory cases, black 
wash or one of the carbolic acid lotions may be applied with a 
sponge or cloth for ten or fifteen minutes at a time, morning and 
evening, and these may be followed each time by an oily prepara- 
tion. If ointments can be used, the following are of value: 

1$. Bismuthi subnitrat., oj (4-) 

Petrol ati, o j. (32.) M. 

Or this: 

1$. Hydrarg. ammoniat., gr. x-xx (0.6.-1.2) 

Petrolati, oj- (32.) M. 

The following is somewhat more stimulating. It appears 
to have a drying effect when there is discharge: 

1$. Hydrarg. chlor. mite, gr. xx-xl (1.2-2.4 ) 

Petrolati, oj- (32.) M. 

A small portion only should be applied at once, but this 
should be rubbed in thoroughly. When a stimulant effect is 
desired, an ointment of the red oxide of mercury, ten to twenty 
grains (.60-1.20) to the ounce (32.), may be employed. The am- 
moniated mercury ointment is particularly useful in cases where 
the eczema is due to the presence of lice. 

When still stronger stimulation is required, especially when 
exudation has ceased, and the scalp is red and scaly, one of the 
following ointments may be employed : 

1$. Ung. hydrarg. nitrat., OJ-iv (4.-16.) 

Petrolati, 3iv. 16. M. 



ECZEMA. 117 

Or, 

1$. Picis liquidae, 5 j ( 4-) 

Petrolati, oj. (32.) M. 

As these cannot be applied when the hair is long, a fluid prep- 
aration must then be employed: 

1^. Ol. cadini, f 3ss ad f oj (2.-4.) 

Ol. amygdalae, ad foj. ( 32.) M. 

Alcohol may be substituted for the oil when the hair is quite 
thick. In some cases, when there is scaly eczema of the scalp 
with some tendency to greasiness, and the occurrence of sebor- 
rhcea, the following ointment acts happily: 

1$. Acidi tannici, 5j (4-) 

Petrolati, 5 j- (32.) M. 

When the hair is long, glycerine and alcohol in equal pro- 
portions may be substituted for the petrolatum. 

Eczema oj the Face. This form of eczema is more apt to be 
met with in children (see Eczema infantile), but is also found 
in adults, on the cheeks and elsewhere. The form of eczema 
found in adults is usually the erythematous, on the cheeks, 
nose, forehead, and sometimes extending around to the ears 
and down the neck. The skin becomes bright or dusky red, 
with intense burning and some itching. It becomes thickened, 
infiltrated, and stiff, with some scaliness. This form of eczema 
is more apt to occur in winter and among persons exposed to 
cold and wind. In addition to such general means of treatment 
as are called for by the patient's condition, active local measures 
should be used. Lead-water lotions are valuable in the acute 
stage, and also black wash. Black wash should be sopped on 
the skin, or laid on by means of rags saturated with it, and re- 
newed hourly. This may be followed by an ointment, especially 
if the patient must move about and cannot keep the wash in 
contact. 

Oxide of zinc ointment with equal part of vaseline may be 
employed, or "Lassar's paste" in some cases. 

In order to protect the skin from cold air, which is very in- 



Il8 DISEASES OF THE SKIN. 

jurious when the skin is in this condition, the following paste may 
be applied: 

1$. Tragacanth. 

Glycerinae, aa oiv (16.) 

Sodii biborat., oss ( 2.) 

Aquas destillat., q. s. M. 

With these materials, a thin, adherent, quickly drying paste 
may be made, with which the skin of the face may be painted 
just before going out of doors. This is almost or quite invisible, 
and yet acts as a perfect protective. On coming in doors it may 
be washed off readily with a little warm water, and then the lotions 
and ointments may be applied. This is worth remembering, 
because not every one can stay at home, day after day, and keep 
applications constantly to his face, and it is well to be prepared 
with some such alternative, which if it does little good yet pre- 
vents much harm to the skin. 

As soon as possible the soothing applications should be changed 
for lotions and ointments containing tar and carbolic acid. The 
carbolic acid wash may be tried even when the eruption is at its 
height, being more apt to be useful if itching, rather than burn- 
ing, should be the prominent symptom. The following formula 
is a good one: 

1$. Acid carbolic, 5iij ( 12.) 

Glycerinae, oj ( 32.) 

Lotio nigra, Oj. (512.) M. 

Water may be substituted for the lotio nigra. 

The proportion of carbolic acid may be increased or dimin- 
ished as the case requires. There is a proprietary solution of coal 
tar which is known as " liquor carbonis detergens, " and which 
is miscible with water, which is an excellent lotion for use in 
this form of eczema; it should be employed in the proportion 
of one part to eight of water or stronger. 

It is closely imitated in the following formula by Duhring: 

1$. Picis mineralis, 5ij ( 8.) 

Alcoholis, fgij. ( 64.) 



ECZEMA. 119 

Strain, and add 

Liq. ammoniae fort., rqviij ( 0.5) 

Glycerinae, f5vj ( 24. ) 

Aquae destillatae, ad f5xij (384. ) M. 

The following combinations may be suggested: 

1$. Liq. carbonis detergens, f 5ij ( 8.) 

Liq. plumbi sub. acetat. dil foij ( 8.) 

Aquae rosae, ad Oss. (256.) 

Or, 

1^. Liq. carbonis detergens, foij ( 8.) 

Pulv. zinci carb. praecip., qv ( 20.) 

Pulv. zinci oxidi, oiv ( 16.) 

Glycerinae, f 5j ( 4-) 

Aquae rosae, ad Oss (256.) 

When ointments are borne, the following is useful in very 
many cases: 

1$. Picis liquidae, oss— oij (2.-8.) 

Ung. aquae rosae, oj. ( 32.) M. 

Now and then fissures and cracks form in the infiltrated skin, 
especially about the alae nasi. The following pigment is very 
efficient in healing these, and may often be used as a protective 
over other parts of the face, where there is no objection to the 
discoloration: 

I}. Ol. cadini, 5j (4.) 

Liq. gutta perchae, seu collodii, o j. (32.) M, 

Let a brush be put in the cork, and let the patient paint the 
skin over several times a day. This pigment has the advantage 
over ointments that it cannot be rubbed off. 

Another excellent ointment in erythematous eczema of the 
face is this: 

1$. Ung. hydrarg. nitrat., 

Olei cadini, aa oj ( 4-) 

Pulv. zinci oxid 3ss ( 2.) 

Ung. aquae rosae, ad oj (32.) 

Ol. rosae, q. s. M. 

Eczema oj the lips is ordinarily accompanied by swelling, 
redness, heat, infiltration, slight scaliness, and fissures. The 



120 DISEASES OF THE SKIN. 

muco-cutaneous surface of the skin outside may be attacked, 
and the symptoms and treatment differ according to the seat 
of the eczema. Eczema of the lips is to be distinguished from 
herpes and syphilis. Herpes runs a distinct, short course, and 
is composed of discrete, well-marked vesicles or groups of vesic- 
les. Eczema is more obstinate, and covers a larger surface. 
Syphilis occurring about the mouth usually either assumes the 
form of circumscribed, more or less irregular erosions on the 
inside of the lip, or else is seen localized in the angles of the 
mouth, forming a more or less deep fissure and secreting a puri- 
form fluid. Eczema of the lips, especially when occurring on 
the muco-cutaneous surface, is difficult and painful to treat. 
Solution of caustic potash, twenty grains (1.20) to the ounce 
(32), is of use when there is infiltration. The muco-cutaneous 
surface should be carefully dried before it is applied, and after- 
wards, to prevent running. Ordinarily, milder preparations are 
best. The following is a useful combination: 

1^. Acidi phosphorici, dil., 

Glycerinae, 

Syrupi, aa f§ss. (16.) M. 

Sig. — Apply to parts three times daily. 

The same formula, with the addition of enough water to 
make six ounces (192.), may be given internally in teaspoonful 
doses thrice daily. When a dry, wrinkled, scaly condition exists, 
G. H. Fox suggests the use of an ointment containing five grains 
(0.3) of thymol to the ounce (32) of cold cream. 

When the outer edge of the lip is affected, the following oint- 
ment is useful: 

1$. Zinci oxidi, 

Mellitis, aa 3ij (2.66) 

Olei amygdalae, ovj (24. ) 

Cerae flavae, 3ij. (8. ) M. 

In winter a condition analogous to eczema produces annoying 
fissures of the lip, which may be treated by moistening the 
fissure and applying a pointed stick of nitrate of silver. After- 
ward the compound tincture of benzoin may be painted on as a 



ECZEMA. 12 T 

protective. Another procedure in chronic cases is to forcibly 
tear open the crack a short distance and then rub in, by means 
of a bit of cotton on a stick, a minute quantity of strong red 
oxide of mercury ointment, forty to sixty grains (2.66~4)to the 
drachm (4). 

There is a form of eczema occurring on the upper lip, about 
the opening of the nostril. This has been considered under 
eczema of the nares. 

Eczema 0} the eyelids often occurs in scrofulous and badly- 
nourished children, and less frequently among adults also. The 
follicles of the eyelashes are involved, small pustules forming, 
which dry into crusts, gluing the edges of the lids together. 
These are usually more or less red and swollen. Conjunctivitis 
may or may not be present. The treatment varies, according 
to the severity of the case. Mild cases require no more than 
the application of a weak nitrate of mercury ointment, made of 
the officinal ointment diluted with three to six parts of cold cream, 
or an ointment of ten grains (0.65) of red oxide of mercury to the 
ounce (32.) of cold cream. In severe cases the eyelashes should 
be extracted, the edges of the lids carefully dried and then 
touched with a camel's-hair pencil moistened with a drop of a 
2 per cent, solution of caustic potassa. This application is to be 
wiped away immediately and the effect neutralized by the applic- 
ation of cold water. The operation may be repeated every 
day until the infiltration, exudation, and itching subside; after 
which one of the stimulating ointments just mentioned may be 
used to complete the cure ; or a small portion of the following 
ointment, may be applied on the inside of the lower lid with a 
spatula and gently worked over the insides of the closed lids 
with the aid of the linger: 

1$. Hydrarg. oxid. flaw, gr. j (0.06) 

Petrolat, oj. (4- ) M. 

Eczema of the nares deserves special mention. Hardaway 
points out that we have two distinct clinical and pathological 
conditions in many cases, eczema and inflammation of the fol- 
licles of the vibrissas, which latter is in effect a folliculitis barbae, 



122 DISEASES OF THE SKIN. 

or coccogenic sycosis, and to which the name Eczema sycosi- 
forme is sometimes given. When simple eczema of the nares 
exists, a similar inflammation is not unfrequently present in the 
upper portion of the nasal passages, and this complicates the 
condition, which is apt to be stubborn to treatment. The mucous 
membrane of the nasal passages is, in its upper portion, so far 
as the unaided vision can reach, dry, red, and glazed. Near the 
nasal orifice excoriations and even shallow ulcers are sometimes 
met with, and the passages are apt to be clogged up with dried 
crusts. Children, particularly ill-nourished infants, are most 
commonly the subjects of this form of eczema, which is to be 
carefully distinguished from syphilitic nasal disease, both by the 
history of the patient, the absence of concomitant syphilitic 
eruptions, or other symptoms, and the fact that the disease is 
always more superficial in eczema, erosions, if present, being 
shallow and secreting serum and mucus rather than pus. 

The local treatment of this form of eczema consists in first 
softening any crusts which may obstruct the nostrils by painting 
with a soft, camel's-hair brush, or dropping into the nostril 
warmed olive or almond oil. When the crusts are thoroughly 
softened, they can easily be removed, but no force must be used. 
The orifices are then gently anointed with some soothing or 
slightly stimulant and astringent ointment, as the McCall An- 
derson ointment. 

When the vibrissas are affected, a sort of furuncle may arise 
just within the nares, accompanied by intense pain and tension, 
and usually resulting in resolution without suppuration. The 
parts being rigid, there is no room for extension of the inflam- 
matory process. The outside integument of the nose often be- 
comes red and subsequently desquamates. 

The disease process may run its course in a few days, or, by 
the extension of the inflammation to new follicles, may drag on 
over several months. In chronic cases one is sometimes con- 
sulted rather for the redness of the nose than for the actual dis- 
ease. 

The affection appears to attack persons who have become 



ECZEMA. 123 

worn out by fatigue, mental strain, or worry. Although not 
strictly speaking an eczema in this form, yet it is so closely con- 
nected with the eczematous inflammation as to deserve mention 
here. Any discharge from the nostrils must be treated as an 
indispensable preliminary to the cure of the skin affection. 

Hardaway recommends cod-liver oil emulsion internally, 
preceded, in some cases, by the sulphide of calcium, in one- 
tenth grain doses every three hours. Locally he advises one 
part of glycerine to two parts of Squires' glycerole of the sub- 
acetate of lead applied freely, by means of a camel's-hair pencil 
to the inside and outside of the nose. Ichthyol applied pure to 
the pustule or pustules often gives relief. Fomentations of 
water as hot as can be borne may be applied several times daily, 
and the hairs should be plucked from the inflamed follicles. 
When the disease spreads down on the upper lip, the sulphur 
and tragacanth lotion (see Acne) is usually the best treatment. 
Local depletion may be required. Later, Hardaway suggests 
the ointment of the glycerole of lead. In severe, long-continued 
cases, where relapses are common, the hair papillae may be de- 
stroyed by electrolysis. 

Eczema 0) the beard is sometimes excessively stubborn and 
annoying. Pustules, usually seated about the hairs, form with 
great rapidity and persistence, and are followed by yellowish 
or greenish crusts, often matting the hairs together. Usually 
the affection is confined to a limited locality, as the corner of the 
upper lip, near the commissure, or just at the beginning of the 
nostrils; but occasionally the whole beard may be involved, and 
the disease may extend to other parts of the face. In this respect 
the affection differs from sycosis (see Sycosis coccogenica), 
which is always limited to the hair follicles. The latter is also 
a deep process involving the follicles themselves, while eczema 
barbae is essentially superficial, occupying the surface of the skin 
alone, and taking in the hair follicles only incidentally. Papules 
and tubercles, not uncommon in sycosis, are absent in eczema 
barbae. The two affections do, however, often resemble one 
another very closely. 



124 DISEASES OF THE SKIN. 

Ringworm of the beard (see tinea Sycosis) is sometimes mis- 
taken for eczema barbae; it is important to distinguish between 
the two diseases. Crusts are generally abundant in eczema; 
in this form of sycosis they are generally (though not always) 
scanty. When the crusts are removed, the eczematous surface is 
smooth, while in tinea sycosis it is rough, uneven, tubercular, and 
lumpy — a very important point. The hairs in eczema are usually 
firm in their follicles, and the attempt to remove them causes 
pain, even when there is a good deal of suppuration about the 
root. In tinea sycosis, on the other hand, the hairs come away 
without the least pain or difficulty; they are often crooked, but 
are usually quite smooth and dry, while the hairs of eczema are 
surrounded by the glutinous root sheath. Above all, the hairs in 
tinea sycosis almost invariably contain the»characteristic fungus; 
besides which, the source of contagion in this highly contagious 
disease can frequently be traced out. Finally, patches of char- 
acteristic ring- worm not unfrequently can be seen on the neigh- 
boring skin. 

The treatment of eczema of the beard should be prompt 
and energetic. The crusts must first be removed with oil or 
poultices, followed by soap and warm water, and then the beard 
must be carefully shaved. This is a painful operation when 
first performed, and patients often rebel against it. It is well 
to be firm, however, and it is sometimes unsafe to take the 
responsibility of a case unless the patient complies with these 
directions. After the first time, shaving is much less painful, and 
patients do not object. Ointments and other applications cannot 
be brought into intimate contact with the surface when there 
are hairs growing upon it. In the acute stage, the treatment 
by sapo viridis and unguentum diachyli, as described under the 
general treatment of eczema, is best. Later, a weak sulphur 
ointment, of half a drachm (2.) to the ounce (32.), or the sulphur 
and tragacanth lotion (see Acne), may be employed. 

Eczema of the ears may occur in any form, and may involve 
either the outside or the meatus. In the acute forms and stages 
the ears are red and swollen, and they burn and itch severely. 



ECZEMA. 125 

The disease, when it involves the meatus, may cause temporary 
deafness from occlusion by large and abundant epidermic 
flakes and scales. Ointments, as a rule, are most useful in eczema 
of the ears, though in the acute vesicular form, black wash, or 
some other lotion, may first be employed, as in the general treat- 
ment of acute eczema. When there is a deep crack behind the 
ear, of long standing, sapo viridis may be briskly rubbed in, 
followed by an ointment containing tar or calomel, a drachm 
to the ounce. This is a good combination: 

J$. Picis liquidae, 5 j (4-) 

Ung. zinci oxidi. 5 j- (3 2 -) M. 

Calomel may be added to this formula. When the meatus 
is involved, if ointments, etc., are used, the opening may become 
gradually clogged with debris, and deafness, often quite alarming 
to the patient, may result. In these cases the meatus is to be 
carefully syringed out with warm water, containing a little borax, 
sodium carbonate, or common salt, in order to remove all the wax, 
epithelium, grease, etc. Oil of sweet almonds may be dropped 
into the meatus first, to soften the mass. Care must be taken 
in these manipulations, and especially in making applications, 
not to injure the membrana tympani. The crusts being removed, 
and the meatus gently dried, the affected parts may be touched 
with a solution of nitrate of silver, two to three grains (0.13-0.2) 
to the ounce (32), and dry charpie applied, or if there is much 
oozing, cold cream in small quantity. If the skin is infiltrated, 
a solution of caustic potash, ten grains (0.65) to the ounce (32), 
may be applied by means of a camel's-hair pencil, carefully 
stripped before introduction, so as not to leave a drop which may 
run down to the tympanic membrane. These applications may 
be made every day or two, and as the acute symptoms pass off, 
an ointment of tannic acid, one drachm (4) to the ounce (32), 
may be substituted for the cold cream. In the intervals of this 
treatment, which must be carried out by the physician, the pa- 
tient may syringe the meatus out once or twice daily with the 
following solution: 



126 DISEASES OF THE SKIN. 

1$. Acid, carbolic, cryst., 

Zinci sulphat., aa gr. xij ( 0.8) 

Glycerinae, f oiij (12. ) 

Aqua? rosae, ad f 5 xij (48. ) M. 

Eczema occurring about the ears, and particularly in the 
meatus, is apt to be stubborn. 

Eczema of the genitals is one of the most painful and distress- 
ing forms of the disease. In the male, the penis or the scrotum 
alone may be involved, or both together. The latter is more 
commonly the seat of the disease, and the tissues of the skin 
here become greatly thickened, swollen, and infiltrated. Moist- 
ure, crusts, and painful fissures along the folds of the skin are 
often present. Itching is a severe and prominent symptom, and 
the disease is apt to be very chronic. In the female the labia 
and even the vagina may be invaded. The affection here is 
even more distressing than in the male. Itching is violent and 
causes extreme misery. The diagnosis is not difficult. Pruritus 
alone is apt to be mistaken for eczema of the genitals, and here 
the absence of visible primary lesions will decide the character 
of the case. The itching comes first in pruritus, and then the 
skin is torn and bleeding, from the scratching. 

Sometimes eczema of the genitals yields quickly to treatment; 
this is when it is recent and superficial; chronic eczema with 
thickening and infiltration is often obstinate to an extreme 
degree.* 

In the acute and superficial form, simple or medicated warm 
baths are often grateful and give much relief. The following 
is a fair sample of the method of making up these baths: 

1^. Potassii carbonat., §iv (128.) 

Sodii carbonat., oij (64.) 

Pulv. boracis, oij ( 64.) M. 

Dissolve in a quart or so of water; add four to six ounces of 
dry starch, placed beneath the water in the hand, which is then 
opened and beaten through. Six to eight ounces of glycerine 
may then be added if thought desirable, and the whole mixed 

* Diabetes should be suspected in severe cases of eczema of the genitals, and 
the urine should be examined. 



ECZEMA. 127 

in with about thirty gallons (60 liters) of hot water in a long bath 
tub. The patient remains in the bath for fifteen to twenty 
minutes. On coming out the parts are to be carefully dried 
without rubbing, and then at once thickly dusted with powdered 
subnitrate of bismuth, or wrapped up in an ointment composed 
of one part of cod-liver oil to two parts of suet. 

When baths cannot be taken, or even when these are employed, 
it will often be found advantageous to use between times lotions of 
lead- water or black wash, or the fluid extract of grindelia robusta,t 
two drachms (8.) in a pint (512.) of water. If the patient is obliged 
to go about his work or business, it will be well, if he be a man, that 
the part be wrapped or supported in fine linen wrappings to protect 
it. One of the various dusting powders, as nitrate of bismuth 
lycopodium, magnesia, etc., may be dusted on, or if powders 
are found too drying, a little vaseline may be smeared over the 
surface. In both men and women it is important to keep adja- 
cent parts separate from one another, as the heat and moisture 
engendered infallibly make the disease worse. 

Where there is infiltration the treatment must be different. 
Whatever applications are made, however, will do more good 
if the parts are first bathed with water as hot as can be borne. 
The sapo viridis and unguent um diachylon treatment, described 
above, under the head of general treatment, is a most excellent 
method for use in chronic and indurated eczema of the genitals 
when it can be had. When there is considerable itching car- 
bolic acid wash — acid carbolic, 5 n j ( I2 > glycerine, §j (32.) ; aqua?, 
Oj (512) — is of advantage. It is particularly useful in eczema 
of the female genitals, and its application, which may be prac- 
ticed at intervals of a few hours, should be preceded, when pos- 
sible, by bathing with hot water. In eczema of the scrotum, 
when there is much itching, the following application may be 
employed : 

1$. Argenti nitrat., gr. x-xxx ( 0.65-2.) 

Spiritus ceth. nit., f o j- (32.) M. 

This is to be painted on the parts, and will serve to protect 
them; if found too stiff, some ointment may be applied as soon 



128 DISEASES OF THE SKIN. 

as the pigment is dry. Stimulating ointments, mercurial, tarry, 
etc., as given above, may be employed from time to time, as 
required, and one thing should be tried after another until relief 
is gained; for in this form of eczema, more than in any other, 
perhaps, the treatment must, of necessity, be largely empirical 
and tentative. 

Eczema oj the anus is not very common — pruritus of this 
region being usually mistaken for this disease — but when it 
occurs, may cause much infiltration and fissuring, with not 
unfrequently involvement of the neighboring parts. It is very 
apt to result from a neglected pruritus of this part. (See Pru- 
ritus ani.) It usually assumes the erythematous form, and when 
fissure results great pain is experienced on defecation. On 
account of this, constipation from over-retention of the faeces 
is commonly present, with the effect of heightening the discom- 
fort and pain caused by the passage of the stools. Itching and 
burning sensations, worse at night on going to bed, and in 
severe cases pain on defecation — these are the chief symptoms 
of eczema ani. The treatment is, in general, the same as that of 
infiltrated eczema in other localities. The parts should first 
be washed with ichthyol soap or with a mild sublimate soap. 
The following ointment may then be applied: 

1$. Acid boric, oj (4-) 

Cocaine hydrochlorate, 3j (4-) 

Lanolin, oj- (32.) M. 

Tar ointments in various proportions are very useful. The 
following formula gives the tar in the least offensive form possible, 
first applying a five per cent, solution of cocaine hydrochlorate 
to prevent undue pain: 

1$. Picis liquidae, oj (4-) 

Medullas bovis, 5 vj (24.) 

Cerae albas, oj (4-) 

Ol. rosas rr\y. ( 0.3) M. 

Almond oil containing twenty per cent, carbolic acid forms 
a cleanly and not disagreeable application. It may be rubbed 



ECZEMA. 129 

n with the fingers every night on retiring. Even when the 
mucocutaneous surface is abraded and fissured, this oil gives 
relief, while many applications pain severely. When there 
are deep fissures, these should be split open and touched with 
the nitrate of silver stick, the tar ointment being subsequently 
applied. The parts should be kept scrupulously clean, and the 
patient should be exhorted not to scrape and dig at the skin, but 
to fly to his ointment or oil when the attack comes on, and es- 
pecially to keep these close at hand when undressing for the 
night. If there is any tendency to congestion and moisture about 
the nates and perineum, these should be powdered with starch or 
astringent powders. Laxatives, by permitting the passage of 
the faeces in a softened condition, and also possibly by relieving 
the circulation in the hemorrhoidal veins, may often be of service. 
The astringent injection mentioned under pruritus ani is often 
of great service. 

Eczema intertrigo resembles erythema intertrigo (see Ery- 
thema intertrigo), but shows the characteristics of eczema. The 
parts should be dusted frequently with astringent powders, 
kept from rubbing, if possible, by the interposition of lint or 
cloth, and rest, when possible, should be enjoined. Sometimes 
astringent lotions are useful. 

Eczema oj the breasts may occur about the nipple or on the lower 
edge of the breasts. The former variety is often brought about or 
kept up by nursing. The diagnosis, especially from syphilis and 
from Paget's disease which is very important, is to be made by ex- 
clusion. Eczema occurring in this locality shows the infiltration, 
redness, exudation, burning, itching, etc., characteristic of the affec- 
tion. The sapo viridis and unguentum diachylon treatment, or that 
by solutions of caustic potash, is the best when there is much 
infiltration. The treatment in every case should be decided 
and vigorous. When fissures of the nipple occur in nursing 
women, leaden shields may be used and the cracks in the nipple 
moistened, touched with nitrate of silver stick (an excessively 
painful operation for the moment, but the pain of which can be 
reduced by previously touching the cracks with a twenty per 
9 



130 DISEASES OF THE SKIN. 

cent, solution of cocain hydrochlorate), and painting with com 
pound tincture of benzoin. By this means cracks in the nipple 
can often be healed up while the child is nursing. When eczema 
occurs about the lower edge of the breast it generally takes on 
the form of eczema rubrum or eczema intertrigo, and is in part 
due to a pendulous condition of the mammae. The usual treat- 
ment of lotions, as black wash, astringent powders, and the in- 
terposition of lint or absorbent cotton will work a cure. 

Eczema oj the umbilicus is usually moist and fissured. A 
disagreeable odor generally accompanies the affection in this 
locality, and there are scales and crusts. The disease is apt to 
be mistaken for syphilis if it occurs only in this locality, but in 
syphilis ulceration usually takes place, and the smell is more 
than disagreeable; it is positively offensive. The little pit should 
be kept thoroughly clean, and the diseased part should be painted 
every day or so with a solution of nitrate of silver, four to ten 
grains (0.24-0.65) to one ounce (32.), and then the sides kept 
apart by dry cotton. 

Eczema of the leg is a very common form of the disease, 
especially among old people. The erythematous and vesicular 
varieties are commonest at the beginning, but these soon change 
to eczema rubrum or weeping eczema. The affection occurs 
in one or more patches of various size, the whole leg being not 
unfrequently involved. When it comes under notice it has gener- 
ally lasted some time ; the skin of the leg is smooth, shiny, dusky 
red or violaceous and unbroken; or it may be moist and weeping, 
or covered in part or wholly with scales and crusts. There is 
always a good deal of thickening and infiltration, with burning 
and itching to an extreme degree. Varicose veins often accom- 
pany this form of eczema, and varicose ulcers are not uncommon. 
Eczema rubrum sometimes occurs in elephantiasis of the legs; 
here it is secondary to the other affection. The diagnosis of 
eczema of the leg is not difficult. Ulcers, when present, are to 
be distinguished from syphilitic ulcers. The treatment of eczema 
of the leg must vary with the nature of the case. In moist, weep- 
ing eczema the sapo viridis and unguentum diachylon treat- 



ECZEMA. 131 

ment is the best when it can be carried out. Next to this is the 
treatment by means of glycerole of the subacetate of lead. Both 
forms of treatment have already been described. A paste sug- 
gested by Unna is often useful. It is composed as follows : 

1$. Kaolin., 

Ol. lini. (seu glvcerinae), aa ovj (24.) 

Pulv. zinci oxidi, 

Liq. plumbi subacetat., aa oss. (16.) M. 

This forms a thick, creamy liquid, which dries with tolerable 
rapidity on exposure to the air. It is best preserved in a bottle 
with a large brush in the cork. This prevents evaporation and 
permits the ready application of the remedy. A thin coating 
is painted on the skin and allowed to dry, which usually occurs 
in a few moments, or if it does not dry quickly enough a little 
powdered kaolin or starch may be dusted over the surface by 
means of a wisp of cotton. A bandage is then applied firmly 
from the toe to the knee, and the dressing allowed to remain in 
place for twenty-four hours. At the end of that time, the band- 
age being removed, the dried paste can be readily detached. 
When it sticks closely to the skin it is better not to tear it 
off, but to paint over the whole limb. This process is repeated 
daily, the area covered diminishing with the healing up of the 
disease, until, finally, pigmentation occurs. Ravogli uses, first, 
a liniment of two-per-cent. ichthyol in a mixture of glycerine, 
almond oil, rose water, and lime-water, applied on patent lint 
and covered with a layer of cotton. Subsequently he uses 
oxide of zinc ointment or diachylon ointment, containing six- 
per-cent. ichthyol. 

An excellent treatment for chronic eczema rubrum of the 
leg, complicated, as this so often is, by ulcers, is the following: 

After cleansing the ulcer from all debris, secretion, etc., it 
is covered with powdered iodoform, aristol or europhen thickly 
dusted on. The whole area of eczema around the ulcer and 
extending to the entire limb if required, is then painted with 
the following: 



132 DISEASES OF THE SKIN. 

1^. Acid, salicylic, 

Acid, carbolic, aa 3ij ( 8.) 

Zinci oxid., giv (128.) 

Mucilag. tragacanth, 

Glycerin, aa Sxiiiss ( 54.) 

Aquse destillat., §iv. (128.) 

The proportion of oxide of zinc may be varied slightly so as 
to obtain the consistency of thick cream. 

After the diseased skin has been well coated with this paint, 
a double-ended roller bandage is to be applied. The bandage is 
to be thoroughly soaked in water and applied while still wet by 
its middle across the foot just below the instep, the ends being 
crossed and recrossed at every turn with a half twist. If care- 
fully applied, this bandage may remain in place for several days, 
or even a week, without arousing any discomfort. It is, there- 
fore, particularly suitable for dispensary patients, and those whose 
circumstances forbid a frequent visit to the physician. 

Occasionally massage may be employed to stimulate the cir- 
culation in the diseased limb and to hasten the absorption of 
the products of inflammation. Before using this procedure, the 
surface should be disinfected by washing with some parasiticide 
soap, followed by a wash of i to iooo corrosive sublimate or 
a saturated solution of boric acid in distilled water. 

When enlarged or varicose veins occur in connection with 
eczema of the leg, particular pains must be taken to support 
the vessels and to give tone to the circulation. The patient 
should sit or lie with the limb in an elevated position, and should 
never permit it to hang down. Walking exercise may some- 
times be taken in moderation with benefit, if the limb has been 
supported by an elastic stocking, or by one of Martin's rubber 
bandages. Bandages of one kind or another should always be 
employed in eczema of the leg, both to support the dressing prop- 
erly, and, as has been said, to give tone to the vessels. Too much 
stress cannot be laid on the importance of attending to the con- 
dition of the circulation in eczema of the leg. The rubber 
bandage is particularly useful in a limited number of cases, 
especially when there are ulcers present. It should be applied 



ECZEMA. 133 

directly to the limb, care being taken to exercise firm and even, 
but not too severe pressure. At night the bandage should be 
removed and cleansed and placed in carbolized water, from 
which it can be removed in the morning and dried previous 
to re-application. The leg should be dusted with starch and 
boric acid; or it may be bathed with hot water containing a little 
carbolic acid, if there is much itching, and then is to be dusted 
with boric acid and wrapped up loosely in a muslin bandage, 
or cloth, for the night. The rubber bandage must be used with 
caution, and the leg frequently examined by the physician. 
If applied carelessly it may do harm by cutting into the skin or 
by macerating it. 

Eczema of the hands may attack cither the back or the palm. 
The appearance and course of the disease is so different, how- 
ever, in one case or the other, that they must be considered 
separately. Eczema vesiculosum is the variety most common 
on the backs of the hands, and on the backs and sides of the 
fingers. Sometimes the pustular variety is found, and occa- 
sionally fissured eczema about the knuckles and pulps of the 
fingers. The vesicular form of eczema is not unlike that found 
in other localities, excepting that large blebs occasionally form. 
It may be acute or chronic, and in some cases the nails are also 
involved in the disease. It is apt to occur as the result of exposure 
to acids, alkalies, brick-dust, etc. The diagnosis between eczema 
and scabies of the backs and sides of the fingers and hands is 
sometimes difficult. In scabies the peculiar burrow of the 
itch insect, a short, irregularly curved, beaded, black line, a 
quarter of an inch in length, is often present, and the vesicles 
are few in number and scattered. In eczema, on the other 
hand, the vesicles are numerous and closely grouped. In 
scabies the vesicles are firm, and usually remain unruptured 
until they are opened by mechanical means. In eczema the 
vesicles usually rupture spontaneously, at an early period. The 
vesicles of scabies commonly exhibit through their summits 
a fine, dark, irregular line, made up of points, being the original 
burrow in the epidermis which has been raised by the formation 



134 DISEASES OF THE SKIN. 

of the vesicle. This is, of course, wanting in eczema. The 
occurrence of scabies elsewhere over the body will also assist in 
the diagnosis. Vesicular eczema of the backs of the hands may 
also be confounded with the rare disease known as dysidrosis or 
pompholyx. (See Pompholyx.) Eczema of the backs of the 
hands, and particularly eczema of the fingers, is apt to be very 
intractable, sometimes recurring every year or oftener, at regular 
intervals. In the acuter forms of vesicular eczema of the backs 
of the hands, lotions, as black wash, and particularly a lotion of 
two to four grains (0.13-0.26) of the sulphate of zinc to the ounce 
(32.) of water, are useful in the more chronic form of the disease. 
Stimulating ointments commonly answer the best purpose in the 
chronic form. When the case is chronic and not very extensive, 
the vesicles may be ruptured by an application of solution of caustic 
potash, twenty to forty grains (1.30-2.60) to the ounce (32.), ap- 
plied with a pointed stick, or brushed quickly over the surface and 
washed off. The application is to be followed by a soothing oint- 
ment. India rubber finger-stalls are sometimes employed with 
success. Fissures in the ends of the fingers should be painted with 
liquor gutta perchae repeatedly for several days, and then allowed 
to remain untouched until the shell which forms peels off. Then 
a weak solution of caustic potassh may be used. The fingers 
being soaked for a few minutes and then dried, after which the 
solution of gutta percha is again to be applied. Eczema of the 
backs of the feet differs in no essential from eczema of the backs 
of the hands. It is less frequent, however, and when it occurs 
is apt to be less extensive and less rebellious to treatment. 

Eczema of the palms and soles presents some peculiar features. 
Owing to the thickness of the epidermis in these localities, the 
appearance of the affection is somewhat marked. Infiltration, 
thickening, more or less callosity, dryness, and fissuring mark 
the disease. It is very chronic and intractable. Sometimes 
deep and painful fissures occur, and when these are found upon 
the feet locomotion is rendered almost or quite impossible. 
The diagnosis of eczema of the palms and soles is often 
difficult. It is apt to be confounded with psoriasis and syphilis. 



ECZEMA. 135 

From psoriasis, eczema differs in showing, at times, moist and 
bloody fissures, while those of psoriasis are usually dry, and show 
little disposition to bleed. The patches of eczema are usually 
larger than those of psoriasis, and their edges pass gradually 
into the healthy skin. The patches of psoriasis are smaller, 
darker, covered with more abundant and paler or white scales. 
But the best point in diagnosis is the appearance of the disease 
on other parts of the body. When the palms and soles alone 
are affected, it is sometimes hardly possible to distinguish eczema 
from psoriasis. The latter, however, is exceedingly rare, so 
that the chances are one hundred to one in favor of any given 
case turning out to be eczema. The diagnosis between eczema 
and syphilis of the palms and soles is not usually so difficult, 
although sometimes, when the affection is not found elsewhere, 
one may be puzzled to come to a decision. The infiltration of 
syphilis is of a firmer nature than that of eczema; it also extends 
more deeply into the skin. The patches are smaller and more cir- 
cumscribed, and sharply defined upon the edge, and they have a 
tendency to spread upon the periphery and to assume the circinate 
form. Eczema is usually much more uniformly diffused; it is 
apt to be of a light color, while syphilis is darker, and some- 
times ham-colored. It is also apt at times to itch, while syphilis 
does not itch. The history, and especially the occurrence of 
concomitant lesions elsewhere, will often aid the diagnosis. 

The treatment of eczema upon the palms and soles must be of 
the most active and vigorous character, if relief is to be expected. 
The first point is to get rid of the thick epidermis. This may be 
accomplished by covering the palm with rags, spread with sapo 
viridis or wet with a five- to ten-grain solution of caustic potassh, 
and covered with rubber cloth. These are to be kept on day 
and night, until the epidermis is softened, macerated, and reduced 
to something like its normal thickness. Then stimulating oint- 
ments, containing mercury and tar, may be employed. When 
the physician himself can conduct the treatment of the case, the 
following plan may be employed: Let the affected palm or 
sole be soaked for some minutes in water as hot as may conven- 



136 DISEASES OF THE SKIN. 

iently be borne; and then, after the superfluous moisture has 
been hastily removed, let a twenty to forty per cent, solution 
of caustic potash be firmly rubbed into the affected skin at all 
points, by means of a small mop, made of cotton tied to a short 
stick. If this produces an uncomfortable heat, the surface 
may be washed with pure, cool water; otherwise, the following 
ointment is to be applied directly: 

1$. Hydrarg. ammoniat., 3j ( 1.33) 

Adipis, 3ss ( 2. ) 

Sevi benzoinati, 5ij-9j ( 9-33) 

Ol. amygdalae dulcis, up: ( 0.65) 

Ung. petrolii, ad 3vj. (24. ) M. 

It should be spread over the surface, and also laid thickly 
upon rags and applied; waxed paper being wrapped about each 
finger and placed over the palm, both for cleanliness' sake and 
to aid the effect of the ointment. This is to be repeated daily 
until cracks heal up, the skin becomes thin and supple, and 
begins to assume a healthier appearance. Then the potash 
applications are suspended, and a weak tar ointment — a drachm 
to the ounce — is rubbed in daily, to complete the cure. 

Though the treatment just described is more particularly 
applicable to the palms, yet it may also be employed upon the 
soles. However, a better treatment for that form of eczema 
affecting the thicker skin of the soles is the glycerole of lead 
treatment, described above. 

The salicylated rubber plasters may be used with very good 
effect. These are applied in the form of strips, and moulded 
so as to fit the skin closely, without folds or wrinkles. They 
may remain on for twenty-four hours to several days, but must 
be removed when they become loose, or, in any case, after some 
days. The softened epidermis may then be scraped away, and 
one of the applications above mentioned may be made. The 
plaster should then be again applied until the thickened, horny 
epidermis is removed to a great extent, after which an ointment 
may be applied. 

The treatment of this form of eczema requires even more 



ECZEMA. 137 

patience than that of the other forms. Perseverance, however, 
will finally be crowned by success, unless the patient's general 
condition should be seriously at fault.* 

Eczema, when it occurs upon the nails, shows them deprived 
of polish, rough, uneven, and often punctate or honeycombed. 
The nail becomes depressed, particularly about the root, at 
which point its proper nutrition is arrested. It may gradually 
recover its normal condition, or it may be cast off and replaced 
by a new nail. With regard to treatment, tar ointment, one 
drachm (4.) to the ounce (32.), applied about the root, with the 
internal administration of arsenic, promise the best results. 
When there is much tenderness, unguentum diachylon may be 
used at night, and an ointment of a drachm (4.) of salicylic acid 
to the ounce (32.) of benzoated lard, or a salicylic rubber plaster, 
may be applied in the day time. 

It should be remembered that any blows or pressure applied 
to the end of the nail acts as an irritant, and consequently some 
kind of splint should be used to protect the nail. The rubber 
plaster will serve the purpose if properly applied, and the nail 
should be cut short. Eczema of the back of the fingers is fre- 
quently accompanied by disease of one or more nails, which 
passes away with the eczema or soon after. 

Eczema in Infants. — Infants are liable to eczema from the 
first weeks of extra-uterine life, the chief differences between 
the disease as shown in these cases and as it manifests itself 
in later life being, on the one hand, the restricted causes 
which may give rise to the disease, and on the other hand, the 
different appearance of the eruption, dependent upon the 
peculiar structure of the skin in early life. Eczema in infants 
and in young children is due either to digestive disturbances, to 
teething, or to that inherited weakness of constitution and poor 
nutrition generally attributed to the scrofulous habit. Bottle- 
fed infants are most apt to suffer from ind'gestion, and these are 
also most liable to the eruption of eczema. While too much 

* Of late I have used the X-ray with excellent effect, alone or in connection 
with the older forms of treatment. For the technique see Allen or Pusey and 
Caldwell's Treatises on Radiotherapy. 



138 DISEASES OF THE SKIN. 

stress must not be laid upon the irritation of teething as g.ving 
rise to eczematous eruptions, yet when the tendency to eczema 
exists, each tooth, as it comes out, will often be accompanied 
by an eczematous rash, which fades away as the tooth develops. 
It will be found, on observation, that the children of parents 
who suffer from a tendency to phthisis, or who present the symp- 
toms commonly associated with the idea of scrofula, are most 
apt to be attacked with eczema, even when fed on the breast and 
presenting no signs of indigestion. When, as among the lower 
classes, improper nourishment and bad hygienic surroundings 
are added, the disease sometimes takes on a quite severe form. 

In children who suffer from repeated attacks of eczema, last- 
ing after the period of teething, and without either disturbed 
digestion or the scrofulous taint to account for the persistence 
of the disease, the skin will often be found to present that dryness 
and rough, scaly appearance usually associated with ichthyosis, 
and the ichthyotic condition will grow more marked as the 
child grows older. 

Moreover, asthma is a not unfrequent complication or accom- 
paniment of the chronic eczema of childhood, and I have seen 
several cases where eczema, ichthyosis, and asthma occurred in 
the same individual. 

The diagnosis of infantile eczema is usually not difficult. 
About the buttocks, genitalia, and folds of the neck it com- 
monly occurs in the form of E. erythematosum or E. intertrigo. 
In the former locality it may be mistaken for syphilis, but the 
absence of deep infiltration, and, above all, the absence of 
characteristic syphilitic lesions, whether of the palms and soles 
or of the body generally, will usually assist the diagnosis. The 
vesicular and pustular form is that commonly met with upon the 
cheeks, behind the ears, and about the head generally. It some- 
times runs on to E. rubrum, with very abundant discharge of 
serum. Occasionally shallow ulcers with crusts form, and in 
this variety it is at times difficult to say whether we have eczema 
or syphilis. Especially is this the case when the child is poorly 
nourished and emaciated. But in syphilis we are apt to have 



ECZEMA. I39 

''snuffles," cracks in the commissure of the lips, and lesions about 
the anus; also, some of the lesions are apt to be infiltrated, and 
to show deeper ulceration. Eczema tends to itch to a marked 
degree, and this alone will commonly distinguish it. Papular 
eczema is more apt to occur in older children; it may very readily 
be mistaken for scabies, but the points given under that head 
(see Scabies) will serve to distinguish between the two affections. 
The treatment of eczema in infants must depend, to some 
extent, upon the cause. When indigestion seems to be at the 
bottom of it, the food must be changed and regulated. The 
physician, who desires to treat such cases of infantile eczema as 
come under his care with satisfaction and success, must study, 
in each case, to obtain suitable food, and see that it is properly 
administered. Constipation in infants is a frequent cause of 
eczema, and should be combated. If habitual, the food should 
be changed with the view of improving this condition, while for 
occasional use the following powder may be administered: 

1$. Hydrarg. chlor. mitis, gr. xij fo.S) 

Pulv. rhei. gr. xviij (1.2) 

Magnesiae calcinat 5ss. (2. ) M. 

Div. in chart No. vj. 
SlG. — One every morning. 

This is the dose for an infant of eight to ten months; the 
quantity, of course, should be regulated according to the general 
condition of the child, as well as its age. It should not be given 
for more than a few days successively, and purging should be 
avoided. I find this a very useful powder in eczema of an acute 
or semi-acute character in constipated infants. If there is 
vomiting and dyspepsia, then lactopeptine, or pepsin and bis- 
muth, may be administered. 

When general debility exists, particularly when there is a 
scrofulous taint, syrup of the iodide of iron, in doses of five to 
ten drops, even in infants of a year old, may be administered. 
Sometimes, also, cod-liver oil, internally or by inunction, may be 
employed. 

The external treatment of eczema in infants will depend upon 



140 DISEASES OF THE SKIN. 

the form of the disease present. When this is erythematous, 
and situated about the buttocks, genitalia, and folds of the neck, 
astringent dusting powders, as kaolin, oxide of zinc, and sub- 
nitrate of bismuth, may be employed; while parts that are in 
apposition should be separated by a thin wisp of absorbent 
cotton. Starch powders often do more harm than good in these 
cases, because they soon get moist, caked, sour, and irritating; 
but by the addition of boric acid this may be obviated. Black 
wash and dilute lead-water may be used in some cases. Oint- 
ments are generally not well borne in this form of eczema. In 
vesicular and vesiculo-pustular eczema, and especially in eczema 
rubrum about the face and head, ointments are more useful. 
Scales and crusts should be cleaned away as much as possible, and 
then the milder and astringent ointments may be used first, and 
later those of a more stimulating character. Powdered boric 
acid may be applied when there is moisture, and an ointment 
of boric acid, a drachm to the ounce of petrolatum, may be 
applied. The following are convenient formulae: — 

1^. Pulvis zinci carbonat., 5j (4-) 

Ung. cucumis, 5 j- (32.) M. 

1^. Bismuthi subnitrat., 3j (4-) 

Ung. aquse rosae, 3 j. ( 32.) M. 

In the more chronic forms of eczema rubrum of the face and 
scalp, more stimulating ointments are well borne, as this: 

1$. Picis liquidae, 3ss ( 2.) 

Pulv. zinci oxidi, 5ss ( 2.) 

Ung. aquse rosae, oj- (32.) M. 

Another excellent ointment for use in the more chronic forms 
of eczema in children is the following: 

1^. Sulphuris praecipitat., 

Picis liquidae aa 5ss-j (2.-4.) 

Ung. zinci oxidi, oj- ( 32.) M. 

Instead of anointing with ointments, the cheeks and scalp, 
or other affected parts, may be painted with the following pig- 
ment, which is very effectual, and cannot be rubbed off like 
the ointments: 



ECZEMA SEBORRHCEICUM. 1 4 1 

1$. Ol. cadini, 3 j (4-) 

Collodii, 5j. (32.) M. 

Put a camel's-hair brush in the cork. 

The prognosis of infantile eczema is almost always favorable, 
and every effort should be made to cure the disease. The opin- 
ion formerly held by some that it is dangerous to cure infantile 
eczema has no basis in observed facts. 



ECZEMA SEBORRHCEICUM. 

Eczema seborrhceicum was the name first given by Unna 
to a group of diseases formerly included under the name pity- 
riasis capitis, seborrhea capitis, seborrhea corporis, seborrJiwa 
sicca, etc., together with certain anomalous forms of eczema 
which had formerly been grouped under that head. 

In its typical forms eczema seborrhceicum almost invariably 
begins on the scalp and often remains limited to this region, 
though frequently it extends to the ears, temples, forehead, 
neck, and adjacent parts. On the scalp the disease may show 
itself in the form of greasy scales or crusts or in a rather dry and 
branny exfoliation. As it reaches the edge of the scalp and 
extends beyond it, it shows a sharply defined red border. Xext 
to the scalp the thorax is most frequently affected. Here the 
affection shows itself in yellowish or fawn-colored, greasy, scaly 
patches and circles confined for the most part to the sternal 
region though occasionally spreading beyond it. The inter- 
scapular region is also a favorite locality. 

In these localities the disease may remain located for months 
or years or in some cases an extension may take place to other 
parts of the body especially where the sebaceous and perspiratory 
glands are largest and most active as in the axillae and groins. 
In most cases the disease runs its course unchanged but occa- 
sionally a transformation to the ordinary forms of moist eczema 
may occur in which the characters, both clinical and histological, 
of the original eczema seborrhceicum are lost. In other cases, 
especially in children, eczema seborrhceicum may show many 



142 DISEASES OF THE SKIN. 

of the features of psoriasis and may indeed appear to develop 
into the latter. Such cases, if really seborrhceic in character, 
will usually improve under local applications containing sulphur, 
while if essentially psoriasic, the internal administration of ar- 
senic will usually do good. The latter has no effect in seborrhceic 
eczema. 

The etiology of eczema seborrhceicum remains for the most 
part in doubt. Some observers have considered it of a parasitic 
nature but such a variety of organisms have been found in con- 
nection with the disease that it is difficult to assign an exclu- 
sively causative role to any particular one.* Locally, heat, moist- 
ure, friction and other forms of irritation may act as predisposing 
causes. The use of flannel next the skin in workers and those 
who perspire freely is a cause of the disease, whence the name 
" flannel- rash" applied to some of its forms. 

The pathology of eczema seborrhceicum is somewhat the 
same at that of ordinary eczema. Even in the mildest grades 
of the affection as in "pityriasis capitis" Elliott found slight 
inflammatory infiltration around the capillary vessels, etc., while 
in the severer grades the inflammatory infiltration extended to 
the subpapillary plexus, and in higher grades to the entire 
cutis which was then somewhat cedematous. The sebaceous 
glands were normal, the coil glands in many instances were di- 
lated and- contained cast-off epithelial cells mixed with a granu- 
lar debris. 

From other forms of dermatitis and from simple eczema, 
eczema seborrhceicum may be distinguished by its origin in the 
scalp, its oily secretion and crusts, the yellowish color and sharp 
outline of its lesions, its tendency to spread peripherally in cir- 
cinate outlines, and by its lack of marked subjective sensations. 

In some forms of the disease the diagnosis from psoriasis 
is difficult, but the location of the lesions on the flexor rather 
than on the extensor surfaces, the oily character of the scales 
and crusts, the yellowish color, the greasy and scaly center of 

* See Elliott, Morrow's System, iii, for a full account of eczema seborrhceicum. 

Also N. Y. Med. Jour., 1895, lxii, p. 528. 



ECZEMA SEBORRHCEICUM. 143 

circinate lesions undergoing involution and the general course 
of the eruption will usually suffice to distinguish the disease. 

Pityriasis rosea may present appearances identical with those 
of eczema seborrhceicum of the trunk and extremities. The 
lesions in the former disease, however, do not appear on the 
scalp, usually have ill-defined frayed-out borders, and the enlarg- 
ing rings present a dry, fawn-colored center which is free from 
greasy scales. The affection, moreover, runs an acute course, 
rarely lasting more than six or eight weeks as a general thing 
(Hyde and Montgomery). 

The treatment of eczema seborrhceicum is largely local. 
Internal remedies seem to have little effect. On the scalp the 
crusts and scales should be washed off with a medicated 
soap as the empyroform soap or a tar soap. The following 
ointment should then be rubbed well into the scalp, being par- 
ticularly useful where there is any moisture: 

1$. Pulv. zinci oxidii, oiss (6.) 

Sulphur, praecipitat, 5j (4-) 

Terrae siliciae, 5ss { 2. ) 

Adipis benzoinat, oj- (32.) 

An excellent ointment to use on the scalp where the hair is 
not too thick or on the bearded face, sternum, etc., is the follow- 
ing: 

1$. Sulphur, praecipitat., 

Sulphur, sublimat., aa gr. xv ( 1.) 

Hydrarg. ammoniat., gr. xxx ( 2.) 

Petrolati flavae, 5ss. (16.) M. 

Elliott suggests resorcin, 3 to 20 per cent., in alcohol and water; 
Hyde and Montgomery the following: 

1$. Sulphur, praecipitat., 9j _ 5ij ( 133 to 8.) 

Balsam Peru, rr^io ( 0.66) 

Petrolati, jj (32. ) M. 

Sometimes in obstinate cases short, mild exposures to the 
X-ray mav be of service. 



144 DISEASES OF THE SKIN. 

HERPES. 

Herpes is a skin affection, characterized by the appearance 
of one or many discrete, transparent vesicles, varying from the 
size of a pin-head to that of a small pea, commonly occurring in 
groups or clusters and seated on an inflamed base. 

The eruption is apt to occur along the line of distribution of 
nerves. The lesions run a pretty uniform course, lasting from 
eight to ten or fourteen days. The clear serous contents of the 
vesicles first become clouded and then gradually dry up, with the 
formation of yellowish crusts which fall off, leaving transitory 
spots of pigmentation. The appearance of the eruption is usu- 
ally preceded or accompanied, or both, by more or less burning, 
and, in the case of herpes zoster, by pain, either localized in the 
eruption or distributed along the line of the nerve supply. 

There are three forms of herpes: H. simplex, H. pro geni- 
talis, and H. zoster. The affection known as "herpes iris" 
on account of its herpetiform lesions, is a variety of erythema 
multiforme, under which head it will be found described. 

The three forms of herpes are so different in their location 
and course that they are usually described as entirely separate 
and distinct diseases. H. zoster, for instance, rarely recurs 
in the same individual. H. simplex may recur at any time, 
and in some cases does recur periodically, while H. progenitalis 
recurs inveterately in some cases. 

There is, however, some link of union between the affections, in 
addition to their close adherence to the herpetic type of lesion, 
and to their occurrence along the distribution of nerves. This 
is shown by the fact, occasionally observed, of the simultaneous 
occurrence of the different forms of herpes. 

HERPES SIMPLEX. 

This form of herpes was formerly known as H. labialis or 
facialis, but this designation is too narrow, as the eruption may 
be, and frequently is, met with in other parts of the face — the 
cheeks, alae nasi, eyelids, and ears being occasionally attacked, 



HERPES SIMPLEX. 145 

and is also, though rarely, met with on the body or limbs. Oc- 
curring about the lips and nose, the eruption is popularly termed 
"fever blister" or "cold sore." There is a form of herpetic erup- 
tion about the tonsils and adjacent parts, accompanied by high 
fever, and occasionally appearing epidemic in character, which 
closely resembles the so-called "follicular tonsillitis," but may 
readily be distinguished by the strictly herpetic character of the 
lesions.* 

When the lips are attacked by herpes simplex, one only is 
usually affected, the lesions commonly occurring at the bound- 
ary between the skin and the mucous membrane. The lower lip 
is most frequently attacked. The lesions here not infrequently 
coalesce and form a bleb. The contents of the vesicles dry 
up within from three to six days, and form brownish or yellow- 
ish crusts which loosen and fall off spontaneously. When the 
crusts are prematurely detached the cure is delayed. 

Herpes of the lips is a frequent concomitant of various gen- 
eral disturbances. Slight ailments of the digestive organs, 
affections of the chest, as pneumonia or pleurisy, malarial fevers, 
etc., are often accompanied by an outbreak of herpes of the lips. 
Some women have an eruption of herpes on the lips before, 
during, or after each menstrual period. f Eruptions of herpes 
of the lip are observed repeatedly following the use of a dental 
instrument in filling the teeth. 

Herpes may occur upon the mucous membrane of the tongue 
and of the oral cavity generally. The lesions here lose their 
vesicular character, because the epidermic cover is macerated 
away almost as quickly as it forms, and a shallow ulcer, the 
well-known "canker" of the mouth, results. 

Herpes of the nostril and alae nasi is a frequent result of a 
cold in the head. It presents no peculiarities other than those 
mentioned in speaking of herpes of the lips. 

Herpes simplex is almost unquestionably a neurosis of the skin. 

* For an excellent description of the various forms of herpes of the pharynx 
see Lermoyez and Barozzi, Annates de Derm, et de Syph., 1897, p. 791. 

fSee Bergh, Herpes Menstrualis, M onatshejt. /. Prakt. Dermatol., vol. x, 1890, 
p. 1. 



146 DISEASES OF THE SKIN. 

Although in no case has any anatomical change in the nerve 
trunks, in the ganglia, or in the nerve centers, been found, as 
in H. zoster, to account for its occurrence, yet the facts that it 
is found in the areas of distribution of certain cutaneous nerves, 
that it resembles so closely H. zoster, and that it seems sometimes 
to occur as the result of reflex impressions, all point to a nervous 
origin. 

The diagnosis of herpes simplex is rarely difficult. The 
peculiar discrete character of the eruption, the well-filled vesicles, 
each on a more or less inflamed base, sometimes coalescing in 
the later stages, but always showing the character of distinctness, 
the fact that the group of lesions is sharply defined, and also that 
the lesions tend to dry up in their entirety rather than to run 
together, point toward the disease in question. Moreover, 
the fact that herpes runs a regular and strictly limited course 
is highly characteristic. 

Herpes upon the line of junction between the skin and mucous 
membrane, and upon the mucous surface of the lips, especially 
when it occurs near the commissure, may sometimes be mis- 
taken for the initial lesion of syphilis or for mucous patches. 

From the initial lesion of syphilis, herpes is distinguished by 
its more superficial character and the absence of infiltration, as 
well as by the absence of glandular involvement, the submental 
and other neighboring glands being invariably involved in con- 
nection with the syphilitic lesion. 

Mucous patches in the oral cavity are sometimes mistaken 
for herpes, but the mucous patch is almost always much larger 
and more superficial, with a squarish outline and a flat gray 
floor, with usually a narrow red border. The herpetic ulcer 
is small, circular, or "polycyclic" in outline, with sharply-defined 
edges. 

Herpes upon the skin of the face may be mistaken for 
herpes zoster and for eczema, and, possibly, in rare cases, for 
dermatitis venenata. From H. zoster it is distinguished by the 
absence of neuralgia and the more diffuse outline of the grouped 
lesions. Moreover, herpes zoster never, in my experience, 



HERPES SIMPLEX. 147 

attacks the opening of the nostrils or the muco-cutaneous junc- 
ture of the lips. H. simplex facialis likewise runs a more 
rapid course than H. zoster. 

Eczema vesiculosm of the face is always marked by the fact 
that the commingled lesions run together, and are never made 
up of discrete vesicles. There is also an absence of the red 
base observed in the lesions of H. facialis, and in eczema some 
characteristic lesions are almost always found in places rarely 
or never attacked by herpes. Finally, the course of an eczema 
is not a brief and limited one like that of herpes, but tends 
rather to an irregular and often chronic prolongation. 

Dermatitis venenata shows lesions often resembling those 
of herpes, but the distribution is almost invariably different, 
and the tendency to spread and to appear in other localities is 
quite marked. There is, furthermore, in dermatitis venenata, 
almost always a history of exposure to the emanations of the 
poison vine. 

The treatment of herpes simplex is very simple, being confined 
to the local use of soothing and emollient applications. In 
herpes of the lip a little cold cream, or diluted oxide of zinc 
ointment, is usually all that is required. Sometimes the oleate 
of bismuth ointment (see McCall Anderson ointment, under 
Eczema), with the addition of europhen or some other antisep- 
tic, is useful. Care must be taken not to detach the crusts 
prematurely, as this lengthens the duration of the affection. 
In cases of extensive herpes of the face, like the one described 
above, a soothing application, as a poultice of bread crumb and 
dilute lead-water, sprinkled with powdered boric acid, mil give 
relief, a mild ointment being substituted for this when the crusts 
begin to form. 

The prognosis is very favorable in all cases of herpes 
simplex, the affection running a definite course. Its duration, 
however, cannot be shortened, and all the popular remedies 
for cutting short an attack of herpes of the lip must fail ex- 
cept in cases in which the lesions themselves are abortive and 
ephemeral. 



I48 DISEASES OF THE SKIN. 



HERPES PROGENITALIS. 



Herpes progenitalis is found on both males and females. 
The vesicles are usually four to six in number, varying in size 
from that of a pin's head to that of a split pea. They occur usu- 
ally close together and are apt to coalesce. The whole area 
covered by the group of lesions is rarely greater than that of a 
ten-cent piece, or, at most, a quarter-dollar. The parts usually 
affected are, in the male, the preputial sulcus, the lining of the 
prepuce, the glans, the margin of the prepuce, and, more rarely, 
the shaft of the penis. Now and then herpes of the mucous 
membrane of the urethra is met with, when a discharge, liable 
to be considered gonorrhoea!, accompanies it. This condition 
may account for some of the cases of "clap" occurring in males 
who have never indulged in sexual connection. 

Occasionally severe neuralgic symptoms accompany the out- 
break of genital herpes in the male, having often no relation in 
intensity to the severity of the skin eruption. A single vesicle 
may be present in connection with excruciating neuralgic pains, 
not confined to the penis only but radiating to the perineum, 
buttock, thigh, and leg. Unfortunately this distressing variety 
of herpes genitalis is apt to be recurrent. In women, herpes 
progenitalis is uncommon, excepting among prostitutes. 

The lesions are found upon the labia minora, prepuce of the 
clitoris, labia majora, clitoris, introitus vaginae, and, more rarely, 
on other neighboring parts. The attention of the patient is 
called to the eruption by a slight itching and burning sensation; 
a small, red patch is observed, on which a crop of vesicles, at 
first clear, but soon becoming purulent, is seen. . If situated 
on the mucous membrane the vesicle soon breaks down, so that 
the lesion which is, in fact, first noticed is a superficial erosion. 
Unless irritated, the lesions tend to heal within a week or two. 
The tendency to relapse is very marked. In the female it may 
recur with each catamenial period, while in the male each coitus 
may be followed by an outbreak. Venereal diseases of a non- 
syphilitic character, as gonorrhoea and balanitis, seem to predis- 



HERPES PROGENITALIS. 1 49 

pose to the occurrence of the affection. It is much more common 
in the male, during the period of youth and early manhood, but 
in the female may occur up to middle age. Herpes progenitalis 
is apt to be mistaken for chancroid. In the earlier stages, sub- 
sequent to the opening of the herpetic vesicle, indeed, the individ- 
ual lesions are almost identical in appearance in both diseases.* 
The number and distribution of the lesions is a great help. 
The lesions of chancroid are not so numerous as those of herpes, 
and are not grouped together in the way the latter are. When 
multiple, the lesions of chancroid are the result of auto-inocula- 
tion, and are, therefore, of different ages. Time, also, shows 
the difference. After a few days the herpetic sore begins to 
get better, while the chancroid is getting worse. 

The syphilitic initial lesion need not often be confounded 
with the herpetic vesicle. It does not begin as a vesicle; it is 
seldom multiple; it is indurated at some time in its course; is 
accompanied by indurated glands, and does not appear as a 
sore until some days after the exposure.! In the female the 
later syphilitic lesions may sometimes be mistaken for herpes, 
and vice versa. The same principles of diagnosis which come 
into use in distinguishing herpes from the other affections above 
mentioned, will, however, be found of service in such cases, and 
in any case careful observation of the lesions for several days will 
much assist the conclusion. Eczema of the genitalia may resem- 
ble herpes, but the itching and generally severe and more exten- 
sive character of the eczematous disease "serve to distinguish it. 

Herpes progenitalis usually requires very little treatment. 
Sometimes, however, various remedies are required. The best 
remedy for ordinary use is dilute lead-water, applied on a soft 

* Not infrequently, the chancroidal virus is inoculated upon the herpes lesion 
and occasionally a genuine herpes progenitalis may be seen displaying its char- 
acteristic features, these changing afterward to those of chancroid and later as- 
suming the appearance of the initial lesion of syphilis, and followed by the 
generalized lesions of that disease. I have watched this curious procession at 
times and have been obliged to revise my diagnosis once and again with the 
changing appearance of the lesions as their evolution proceeded. 

t In herpes pressure between the thumb and finger will cause a drop of serum 
to exude, while in chancre this usually does not occur, or can only be brought 
about with difficulty. 



i5° 



DISEASES OF THE SKIN. 



piece of linen or a wisp of absorbent cotton. Black wash is a 
good dressing in many cases; or finely-powdered nitrate of bis- 
muth may be used. Sometimes more stimulating applications 
are required. Powdered calomel, sprinkled on the erosions 
morning and night, or equal parts of calomel and oxide of zinc 
may be used. When the disease is prone to recur, astringent 
washes may be employed as a prophylactic. Circumcision is 
sometimes useful in inveterate cases occurring in the male, but 
even this has been known to fail. 

HERPES ZOSTER. 

Herpes zoster is an acute, inflammatory disease characterized 
by the appearance of groups of vesicles, situated upon inflamed 
bases, of unilateral distribution and corresponding in a general 
or particular way to the distribution of certain nerves. 

The eruption is generally preceded and accompanied by 
neuralgic pain. This is often disproportionate to the amount 




Fig. 12. — Herpes Zoster Facialis. 
{After Barensprung.) 




Fig. 13. — Herpes Zoster Labialis. 



of the eruption. Old persons are apt to suffer more severely 
from neuralgia than the young, in fact children are often quite 
free from pain. The eruption makes its appearance in the 
form usually of an inflamed condition of the skin, attended with 



HERPES ZOSTER. 



mi 



heat and burning sensations, and groups of discrete pin-head to 
split-pea sized vesicles, situated on a bright-red surface, appear 
over the region. The vesicles are often crowded together so as 
to coalesce, forming irregular patches. New vesicles continue 
to appear until the fourth, or as late as the eighth day, when the 
eruption is at its height; it remains in this way a few davs, and 
then begins to decrease, the vesicles shriveling, and by the tenth 
day or so drying up, leaving brown crusts, which drop off. 





is / tl. 




Fig. 14. — Herpes Zoster Occipito- 
collaris. 



Fig. 15. — Herpes Zoster Cervico- 
suc-clavicularis. 



The vesicles do not burst, as do those of -eczema. Ten days 
to three weeks is the average duration of an attack. The 
eruption does not always run a typical course. Only a few 
vesicles may appear, or they may abort before fully develop- 
ing. On the other hand, they may suppurate and leave scars, 
though the disease commonly leaves no trace. The neuralgia 
varies from a very slight tingling to the most excruciating pain. 
Herpes zoster may attack any part of the body or even 



152 



DISEASES OF THE SKIN. 



the mucous membranes.* It is commonly found upon the 
trunk and head; less frequently upon the limbs. It fol- 
lows very closely the course of the nerves and Cantrell has 
pointed out that the earliest appearance of the eruption is at 
the point most remote from the affected nerve center. The 
eruption is named according to the region upon which it occurs, 
as H. zoster capitis, H. zoster brachialis, H. zoster facialis, etc. 
On the head it most frequently occurs in the course of the supra- 
orbital nerve, and it may affect the 
eye, giving rise to severe pain. On 
the head, both sides are sometimes 
affected; elsewhere the affection is 
almost always unilateral. The 
chest is the commonest seat for the 
occurrence of the eruption; and 
the names formerly given to the 
disease, "zona," "cingulum" — a 
girdle, indicate this. 



Cantrell, combining my statistics with 
those of Duhring and Stelwagon (Phila. 
Med. Jour., March 26, 1898) found 193 
cases of herpes zoster reported in a total 
of 19,492 cases of skin disease. The af- 
fection, according to Cantrell's analysis of 
these cases, occurs most frequently in the 
months of August, October and Novem- 
ber. The minimum number were encoun- 
January, February and March. Half the cases occurred between 
thirty years. Half the cases also were of thoracic zoster. The 
was a little more frequent upon the left than upon the right side. 




Fig. 16.— Herpes Zoster Cervico 
brachialis. 



tered in 
ten and 
eruption 



Involving the intercostal nerves, the neuralgia often causes the 
affection to be taken for pleurisy, until the eruption makes its 
appearance. 

Dr. R. G. Curtin, of Philadelphia, pointed out to me, some 
years ago, that in all probability some cases of pleurisy are in 



See Fournier, Zona des Muqueuses, Jour, des Mai. Cut. et Syph., August, 1 891. 



HERPES ZOSTER, 



153 



reality cases of herpes zoster. He has since written upon this 
subject.* 

When zoster occurs on the limbs the flexor surface is com- 
monly attacked. It rarely appears below the knees. The 




Fio. 17. — Herpes Zoster Brachialis. 

course of herpes zoster is acute, and, though somewhat variable 
as to duration, it tends to recovery. It rarely occurs twice in 
the same person. Now and then, however, cases are met with 
where it recurs year after year, perhaps six to nine times. f 




Fig. 18. — Herpes Zoster Dorso-abdominalis. 



The disease is usually a descending acute neuritis provoked 
by various causes. The process usually has its beginning in 

* Is Herpes Zoster a Cause of Pleurisy and Peritonitis? Sanitarian, Dec, 1890. 
See also Am. Jour. Med. Sci., 1902, exxiii, p. 264. 

tSee Elliott, Relapsing Herpes Zoster, Jour. Cut. Dis., 1888, p. 324, and 
Grindon, Recurrent Zoster, lb., 1895, pp. 191 and 252. In the latter paper 
which includes an analysis of 61 cases the author shows that most of such cases 
can not be regarded as true herpes zoster. 



i54 



DISEASES OF THE SKIN. 



the ganglionic system — in the cervical or spinal ganglia. The 
eruption does not always follow the distribution of a nerve nor 
even that of interbranching nerves and sometimes it slightly 




Fig. 19. — Herpes Zoster Sacro-ischiadicus. 
(a) Genitalis in female. 

overlaps the median line, due to the interlocking of some fibres 
at their origin. 

In most cases of herpes zoster the ganglia show softening, 




Fig. 20. — Herpes Zoster-ischiadicus. 
(b) Genitalis in male. 

enlargement and inflammation, and the nerves are inflamed 
and thickened. In traumatic and probably other cases (if these 



HERPES ZOSTER. 



J 55 



can indeed truly be included under herpes zoster) the peripheral 
nerves alone may be affected. 

Zoster-like eruptions are not necessarily herpes zoster.* This 
as I have long maintained! is probably an infectious disease 





Fig. 21. — Herpes Zoster Lumbo- 
femoralis. 



Fig. 22. — Herpes Zoster Lumbo- 
femoralis. 



from the fact that it rarely occurs more than once in a lifetime, 
is usually associated with adenopathy, systemic disturbance, etc. J 

"A large list of agencies are named as effective in the production of the 
zoster eruption. Among them are certain poisons (carbon dioxide, bella- 
donna and atropine), pyaemia, carcinoma, fever, measles, pulmonary inflam- 



*See Head and Campbell, The Pathology of Herpes Zoster and its Bearing on 
Sensory Localizations. Brain, 1900, p. 7,2,5. 

t See my article, Recent Views of the Origin and Nature of Herpes Zoster. 
Am. Jour. Med. Sci., Jan., 1902. 

% Cf . Hay, Jour. Cutan. Dis., 1898, xvi, p. 1. Also Walthers' cases of three 
young students successively occupying the same room and being each succes- 
sively attacked by herpes zoster. Allg. Med. Central Zeitg., April 24, 1878. 



156 



DISEASES OF THE SKIN. 



mations (including phthisis), septicaemia, hemorrhages, traumatism and 
malaria. It has also followed vaccination, the passage of electrical currents, 
the extraction of teeth, an accidental prick by a thorn, the tapping of hy- 
datids, and gun-shot wounds of the body. Inasmuch as no one of these 
causes can be cited as certainly effective in all cases, it can merely be said 
that any influence sufficient to induce inflammation of a sensory nerve or its 
ganglion may be followed by the objective signs of the disease." (Hyde 
and Montgomery.)* 





Fig. 23. — Herpes Zoster Cruralis Fig. 24. — Herpes Zoster Cruralis. 

The cutaneous lesions originate in the deeper portions of the 
rete. The exudate from the hyperaemic corium, especially its 
papillary layer, presses upward into the rete, the epithelia of 
which are thus separated and vertically elongated, the lacunae 
between them being distended with serum and a few round 
cells. At the base or sides of the vesicles, either lying free within 



* For a discussion as to the influence of arsenic in producing Zosteriform lesions 
see Neilsen Monatshefte f. Prakt Dermatologie, vol. xi, 1890, p. 302. Also Rasch 
Annates de Derm, et de Syph., 1893, p. 150. 



HERPES ZOSTER. 157 

them or in the oedematous neighborhood of them, peculiar* 
swollen round cells may be observed. These were at one time 
taken for protozoa but their true nature has been demonstrated 
by Unna,* Gilchrist and others. They are known as "balloon 
cells." 

The diagnosis of well-developed typical herpes zoster presents 
no difficulty. The neuralgic pain, the appearance of the vesicles 
in distinct groups, upon a highly inflammatory base, and the 
tendency to preserve their form intact, are characteristic. In 
eczema, which it most resembles, the lesions tend to exude 
moisture, dry up, and crust, while in herpes zoster there is no 
discharge. Eczema itches, H. zoster burns. From simple 
herpes, H. zoster is distinguished by the presence of pain, by its 
non-recurrence, its unilateral character, and by its rare occur- 
rence upon the favorite seats of H. simplex, the lips, alae of the 
nose, and genitalia. 

The treatment of herpes zoster is largely palliative. The 
disease runs a naturally favorable course, tending to recovery, 
and the symptoms of neuralgia and burning in the seat of erup- 
tion alone require treatment. No remedy for internal use is 
known to have the power of aborting or shortening the attack. 
For the neuralgia, phosphide of zinc, in doses of one-third of a 
grain (.02) may be given at the commencement of an attack, 
and repeated every three hours. It may be combined with one- 
third (.02) of a grain of extract of mix vomica. If this fails, in 
severe neuralgic cases morphia may be given at night hypo- 
dermically. Of late antipyrine and phenacetine in 10 grain 
(.6) doses have been employed with marked success. Electricity, 
in the form of the constant galvanic current, often gives relief. 
A continuous galvanic current of between two and three mili- 
amperes may be applied over the root of the nerve two or three 
times daily for ten minutes at a sitting. This application also 
relieves the after pains of herpes zoster, when these supervene 
on the eruptive stage. The vesicles should be carefully pre- 

* Brain, 1903, xxiii, p. 362. Sec also Pollitzer H. Zoster of the hair follicle. 
Jour. Cut. Dis., 1903, p. 73 and Hartzell, lb., 1894, p. 369. 



158 DISEASES OF THE SKIN. 

served from rupture. Powders may be used in most cases with 
advantage. The following is a convenient powder : 

J^,. Pulv. amyli, 

Pulv. zinci oxidi, aa Bss (16. ) 

Pulv. morphias sulphat, gr. ij. ( 0.12) M. 

It is a good plan to sew a soft flannel bandage around the 
affected part, if the locality will admit, after the application of 
this powder, to be removed only when required. This will 
prevent the rubbing of the clothing, which is very irritating. 
Among lotions, lead-water, lead-water and laudanum, fluid ex- 
tract of grindelia robusta, half an ounce (16.) to the pint (512.) 
of water, or the following zinc lotion : 

1$. Zinci ca.rbonat. praecip., 
Pulv. zinci oxidi, 
Pulv. amyli, 

Glycerinae, aa. 3iv ( 16.) 

Aquae, Oss. (256.) M. 

Ointments containing fifteen to twenty grains (1.-1.30) of extract 
of opium or extract of belladonna to the ounce (32.), may be ap- 
plied, spread upon cloths, or rubbed in with the finger, when the 
eruption occurs on the scalp. Among pigments, the essential oil 
of peppermint, painted over the course of the affected nerve, 
and over the vesicles, if unbroken, is said to be a very good ap- 
plication. Billstein recommends salol, gr. xx (1.33), to ether, gj 
(32.), applied locally. Durant observed good results from the 
use of a solution of adrenalin chloride (1-10,000) in the conjunc- 
tivitis accompanying an attack of herpes zoster, involving the 
upper part of the face and forehead on the left side. A solution 
of the same drug (1-1000) in normal sodium chloride solution 
with \ per cent, chloretone applied, by means of a brush, over 
the entire region of the eruption 2 or 3 times a day, absolutely 
controlled the pain. 

The prognosis of herpes zoster is almost always favorable, 
the eruption running its course in a few weeks, in almost all 
cases. Neuralgia is apt to persist, in some cases with abnormal 
sensations, but these in time disappear. In old patients the per- 



HYDROA VACCINIFORME. 1 59 

sistent neuralgia is a very trying symptom. H. zoster of the 
orbital region, however, sometimes endangers the eye, and may 
be followed by deep scars over the scalp with neuralgia and 
anomalous sensations in the skin. Xow and then, herpes zoster 
is a symptom of some form of septicaemia, etc., and is of grave 
import. 

HYDROA VACCINIFORME. 

Hydroa vacciniforme is a recurrent, usually vesicular, scarring, 
summer eruption, beginning in early life almost always in males, 
and as a rule disappearing in adult age. 

The eruption is chiefly or entirely confined to the uncovered 
regions. It begins as a small red spot or papule on the top of 
which a pin-head sized vesicle or bulla develops. This goes 
on to umbilication with a reddish or brownish crust while the 
vesicle is spreading on the periphery which gives it a resemblance 
to a vaccine lesion. Sometimes several lesions coalesce, forming 
a large bleb. The crusts fall off after a time leaving a pitted 
and permanent scar. The disease progresses by successive 
outbreaks and may last for three or four weeks or recur after 
exposure to sun and wind. As manhood approaches the tend- 
ency to the disease diminishes and it finally disappears, in rare 
cases leaving considerable scarring. 

POMPHOLYX. 

This affection originally called by Tilbury Fox ''Dysidrosis" 
is a vesicular and bullous inflammatory disease of the skin 
confined to the hands and feet. 

The disease is far more common on the hands than on the feet, 
it occurs chiefly in the summer. The eruption commences with 
burning and tingling, with the development of deeply imbedded 
vesicles, singly or in groups, along the sides of the fingers and 
on the palms, but no part is exempt, in bad cases. The appear- 
ance of the vesicles has been compared to that of boiled sago 
grains imbedded in the skin. The vesicles never rupture spon- 



l6o DISEASES OF THE SKIN. 

taneously. In ten days or a fortnight the contents are absorbed, 
and the detached epidermis is exfoliated. The disease is most 
common in young women of a nervous temperament and is 
apt to occur in those broken down from worry and ill-health. 
The disease is supposed to be connected with the sweat follicles. 
It is apt to recur. The treatment should be tonic and supporting. 
Locally, soothing ointments with, in some cases, painting with i 
per cent, nitrate of silver solution. 

DERMATITIS HERPETIFORMIS. (DUHRING'S DISEASE.) 

Dermatitis herpetiformis may be defined as a chronic multi- 
form skin affection, characterized by successive outbreaks in 
which the eruption may be at one time herpetiform and vesicular, 
at another pustular, while in other instances, or at other periods 
in the history of a given case, wheal-like lesions or bullae may 
predominate. The lesions tend to assume a circinate arrange- 
ment, and severe and intolerable itching, with more or less 
constitutional disturbance, is a common accompaniment. 

In severe cases prodromal symptoms are usually present for 
several days preceding the cutaneous outbreak; they consist 
of malaise, constipation, febrile disturbance, chilliness, heat, 
or alternate hot and cold sensations. Itching is also generally 
present for several days before any sign of efflorescence shows 
itself. Even in mild cases slight systemic disorder may precede 
or exist with the outbreak. This latter may be gradual or sudden 
in its advent and development. Not infrequently it is sudden, 
one or another manifestation breaking out over the greater 
part of the general surface, diffusely or in patches, in the course 
of a few days, accompanied by severe itching or burning. 

A single variety, as, for example, the erythematous or the 
vesicular, may appear, or several forms of lesion may exist 
simultaneously, constituting what may very properly be desig- 
nated the multiple variety. The tendency is, in almost every 
instance, to multiformity. There is, moreover, in many cases 
a distinct disposition for one variety, sooner or later, to pass 



DERMATITIS HERPETIFORMIS. 



161 



into some other variety; thus, for the vesicular or pustular to 
become bullous, and vice versa. This change of type may take 
place during the course of an attack, or on the occasion of a 
relapse, or, as is often the case, it may not show itself until 
months or years afterward. Not only multiformity of lesion, but 




Fig. 25. — Dermatitis Herpetiforms. Herpetiform variety. 
(Courtesy of Dr. Duhring.) 



irregularity in the course of development is, it may be repeated, 
the rule. Itching, burning, or pricking sensations almost always 
exist. When the eruption is profuse they are intense and cause 
the greatest suffering. They become more violent before and 
with each outbreak, abating in a measure only with the laceration 



162 



DISEASES OF THE SKIN. 



or rupture of the lesions. The disease is rare, but of more 
frequent occurrence than was formerly supposed to be the case. 
It occurs in both sexes and at all ages but usually in adults. 
The disease process is in almost all instances chronic, and 
is characterized by more or less distinctly marked exacerba- 
tions or relapses, occurring at intervals of weeks or months. The 
disposition of the eruption to appear in successive crops, some- 
times slight, at other times severe, is peculiar. Relapses are 




Fig. 26. — Dermatitis Herpetiformis. Bullar variety. 



the rule, the disease in most cases extending over years, pursuing 
an obstinate, emphatically chronic course. All regions are 
liable to invasion, including both flexor and extensor surfaces, 
the face and scalp, elbows and knees, and palms and soles. 
Excoriations and pigmentation, diffuse and in localized areas, 
are in old cases always at hand in a marked degree. The pig- 
mentation is usually of a mottled, dirty yellowish, or brownish 
hue, and is persistent. 



DERMATITIS HERPETIFORMIS. 1 63 

Dermatitis herpetiformis is apt to occur in individuals of 
neurasthenic type or in those in whom the nervous system has 
been subjected to unusual strain. Mental crisis, nervous shock, 
fright, anger, menstrual irregularities, pregnancy, the puerperal 
state, septicaemia, physical fatigue, exposure to cold, and defec- 
tive renal secretion have all been cited as causes of the malady 
(Hyde and Montgomery). 

Examination of the lesions in dermatitis herpetiformis shows 
acute inflammation in the upper part of the corium, dilatation 
of the vessels, marked oedema with infiltration of the lymph 
spaces and some plasma cells. The vesicles are filled with a 
coarse network of fibrin containing polymorphonuclear, with 
some mononuclear and eosinophile cells, red blood and epi- 
thelial cells and coagulated albumin. The deeper portion of the 
corium is unchanged for the most part. Eosinophilia is present 
but its exact significance has not been established. 

The diagnosis is -at times difficult, the affection being liable 
to be mistaken for impetigo herpetiformis, pemphigus, herpes, 
erythema multiforme, and eczema. 

The diagnosis in typical cases is made readily; in others, the 
distinction between dermatitis herpetiformis, impetigo herpeti- 
formis and certain forms of pemphigus is very difficult. It is 
possible that between the three there may be transitional forms 
scarcely to be assigned to one category or the other. The same 
is true of certain exceptional varieties of erythema multiforme 
(Hyde and Montgomery). 

As regards treatment, all authorities agree that this is unsatis- 
factory. So indeed is the treatment in all bullous diseases of 
the skin, but in many instances a careful study of the case will 
lead to an intelligent effort to raise the general nutrition to a 
higher level and to direct the purely medicinal treatment to the par- 
ticular needs of the case. Change of air and scene, a stay at the sea- 
shore or at the mountains or at some mineral springs, when such 
a procedure is available, should be the preliminary to other 
treatment. The usual tonics, cod-liver oil, phosphorus, iron, 
arsenic, strychnia and quinine may also be used. Electricity 



164 DISEASES OF THE SKIN. 

has sometimes been found of value. Among specific drugs, 
arsenic in doses as large as can be borne alone or combined 
with strychnia should be administered. Mackenzie recommends 
10 to 20 minims (0.5 5-1. 12) of the tincture of cannabis indica 
three times a day with 20 grains (1.30) of antipyrine at night. 
Crocker recommends salicine in 20 grain (1.30) doses three times 
a day, increased rapidly up to 25 or 30 grains (1. 65-1. 95). Hyde 
and Montgomery recommend mild laxatives and the free drink- 
ing of water between meals with the occasional administration of 
small doses of a mercurous laxative. 

Locally, washes are often more grateful to the skin than oint- 
ments and are required to sooth the severe itching and irrit- 
ation of the skin. The following is a convenient formula: 

1$. Acid, carbolic, 5iij ( 12.) 

Glycerinae, f o j ( 32.) 

Aquae, ad Oj. (512.) M. 

Elliott suggests ichthyol in a lotion of 25 to 50 grains to the 
ounce of water, or, better, in the following combination: 

Ty. Ammon. ichthyol., gr. xxx-oj ( 2.-4.) 

Olei amygdalae dulcis, 

Aqua calcis. aa. f5ss. (16. ) M. 

This is to be rubbed in several times daily, and allowed to 
remain on the surface; or patent lint, saturated in it, is to be 
bandaged on the affected parts. Frequent starch baths, to 
which bicarbonate of sodium may be added, in the proportion 
of four ounces (128) to the ordinary full bath, sometimes proves 
useful. 

Stelwagon recommends "Liquor carbonis detergens" in 
strength varying from 1 part to 10 of water up to full strength. 

When soothing ointments are required the McCall Anderson's 
ointment, (see Eczema) may be used, or weak sulphur ointments. 
Duhring, however, uses strong sulphur applications.* 

From the number of remedies recommended it may be seen 

* Duhring, The Treatment of Dermatitis Herpetiformis. Am. Jour. Med. Sci., 
Feb., 1801. 



PEMPHIGUS. 165 

that no treatment has as yet proved entirely satisfactory. We 
can but employ one after another until relief is gained. 

The prognosis in dermatitis herpetiformis should be guarded. 
Some cases appear to get well, it may be after months or years, 
but others persist. Relapses are not uncommon. 

PEMPHIGUS. 

A great many different diseases have been included under the name pem- 
phigus, and some recent writers have seemed almost inclined to abandon the 
title entirely as describing an entity. However, it may be convenient for the 
present to continue to group certain affections having the occurrence of blebs 
as their chief characteristic under this head. 

Any one meeting an anomalous case of a bullous character varying from 
the form which I have intended to depict may perhaps find it described in 
literature under some of the following heads: Pemphigus pruriginosus, pem- 
phigus neuriticus, pemphigus hystericus, pompholyx (of Willan and other 
writers), hydroa herpetiforme, hydroa bulleux, pemphigus diutinus, pemphi- 
gus circinatus, pemphigus haemorrhagicus, pemphigus gangrenosus, etc. 
Duhring, in his work, describes the relationship between some of these and 
what he describes as true pemphigus. 

Pemphigus is an acute or chronic inflammatory disease, 
characterized by the formation of a succession of irregularly- 
shaped blebs, varying in size from that of a pea to an egg. There 
are two varieties, P. vulgaris and P. joliaceus. In pemphi- 
gus vulgaris the disease may attack any part of the body, but is 
common upon the limbs. It may also attack the mucous mem- 
brane of the mouth and vagina. The lesions are blebs, from 
beginning to end, forming slowly, or sometimes rapidly in the 
course of a day. They may be few in number or quite numerous 
and often vary greatly in size in the same case. They are 
tensely stretched, like bladders of liquid, and rise directly from 
the level of the skin, which is not usually reddened, and never 
elevated. No case should be called pemphigus the bleb of 
which begins in the form of macules, or large papules. They are 
clear at first, with serous contents, but later are opaque, contain- 
ing a certain portion of pus. They do not rupture spontaneously, 
but gradually dry up, each bleb lasting one to three or six days. 



100 DISEASES OF THE SKIN. 

The lesions are apt to come in crops; they do not burn or itch 
to any marked degree. In adults there is little or no disturbance 
of the general system. In children the disease is apt to be accom- 
panied by feverishness. 

In pemphigus foliaceus the blebs are flaccid and only partly 
filled with fluid, which seems rather to undermine the epidermis 
than to lift it into blebs. The lesions often coalesce, involving 
a large part of the surface; fresh lesions are continually forming; 
the fluid dries into thin, whitish flakes, which are cast off, leav- 




Fig. 27. — Pemphigus. 



ing an excoriated, red surface, and presenting the appearance 
of a superficial scald. The disease may last for years and the 
patient finally succumb to exhaustion. 

Pemphigus vegetans is the name given to an extremely rare affection hav- 
ing the character of a bullous erythema and a pemphigus together, with the 
additional formation of vegetating fungoid papillary growths, closely resem- 
bling condylomata. In fact, the earlier cases observed by Hebra and 
Kaposi were erroneously regarded as syphilitic. 

True pemphigus is a rare disease in this country; only 291 
cases are reported in the 204,866 cases of skin disease of the 
American statistics. It is more common in children than in 
adults. Poor food and bad hygiene, pregnancy and menstrual 



PEMPHIGUS. 167 

disorders, mental depression, general debility and prostration, 
are among the causes. The disease is not contagious. 

The diagnosis of pemphigus is usually not difficult. The 
presence of blebs does not necessarily indicate pemphigus, as 
these are developed in other diseases and by artificial means. 
So-called "pemphigoid" eruptions, obscure in origin and nature, 
are sometimes met with, but their course is not that of pem- 
phigus, properly so called. Pemphigus is not, under any cir- 
cumstances, to be confounded with the bullous syphiloderm, 
formerly called "pemphigus syphiliticus." The latter is a puru- 
lent bleb, drying up into a thick crust, with a deep ulcer under- 
neath. Erythema multiforme, in the bullous form, and impetigo 
contagiosa, are occasionally mistaken for pemphigus. A refer- 
ence to these diseases under their respective titles as well as the 
others above enumerated will show their characteristic points. 

The internal treatment of pemphigus is important. The 
general history and circumstances of the case must be looked 
into, and any defects of constitution or circumstance remedied. 
Among drugs, arsenic is most potent. Fowler's solution, in 
doses of four minims (.22), thrice daily at first, rising gradually 
to the limit of tolerance, may be given. Wine of iron is the best 
excipient for Fowler's solution in these cases. Arsenic produces 
its effects slowly, and it should be persisted in for months, if 
necessary. Even then, a cure, or even amelioration, mav fail 
in so chronic and inveterate a disease. Quinine is of value, 
and in some cases linseed meal, in ounce doses, with milk, has 
proved valuable. Cod-liver oil and stimulants may be required 
at times. The patients should be allowed to rest, and should 
be free from worry and anxiety, so far as this is practicable. 

Local treatment is also important. The blebs should be punc- 
tured and evacuated as soon as they have formed. Soothing 
and astringent lotions, and especially in my experience a tem- 
porary wet dressing of solution of mercury bichloride 1-4000 
to 1-2000 is very useful. Powders of oxide of zinc with the 
addition of iodoform or europhen may be employed. Baths 
containing bran, starch, or gelatine may be used in some cases. 



1 68 DISEASES OF THE SKIN. 

The continuous bath, in which the patient lives, eats, and sleeps 
for months, has been employed in severe cases. Occasionally, 
water does not agree, and in these cases mild ointments, as that 
of oxide of zinc, or diachylon, or one of the pastes mentioned 
under eczema, may be prescribed, always with the addition of 
some antiseptic. 

Pemphigus runs an extremely uncertain course. Relapses 
frequently occur. When the blebs are numerous, flaccid, imper- 
fectly formed, and inclined to rupture, and when they are rapidly 
and frequently formed, the prognosis is unfavorable. Repeated 
febrile attacks also indicate an unfavorable tendency. On the 
whole, then, we may say that the prognosis of pemphigus must 
be very guarded, as even when beginning as a slight attack, an 
unfavorable turn may be taken and the case end fatally.* 

EPIDERMOLYSIS BULLOSA. 

Epidermolysis bullosa is an affection or condition of the skin 
in which there is a strong tendency to the rapid formation of 
bullae whenever the integument may be slightly bruised or rubbed. 
In the majority of cases the disease has existed from infancy or 
early childhood and there is a clear history of heredity. 

The general health of the patient may be excellent and the skin 
may remain sound so long as it is subjected to no irritation, but 
very slight causes as the pressure of a shoe in walking, grasping 
a hammer, etc., may be sufficient to cause the appearance of 
bullae lasting some days, often painful and disappearing without 
leaving a scar. Exceptionally hemorrhagic bullae form followed 
by scarring (Bowen's case). 

Histological examination throws little or no light on the nature 
of the disease. 

* The following references to American literature will be of service to anyone 
who may wish to push the investigation of this subject further than the limits of 
the present volume will permit: Duhring, Cutaneous Medicine, Pt. II, p. 449; 
Pemphigus Neonatorum, Killiam, Am. Jour. Obstetrics, 1889, p. 1039; Ravogli, 
Cin. Lancet-Clinic, 1889; Corlett, Indiana Med. Jour., Nov., 1893, p. 158; Pem- 
phigus Foliaceus, Sherwell, Arch. Dermatol., Jan., 1877, and Jour. Cut. andGen.- 
Urin. Dis., 1889, p. 453: Hardaway, Jour. Cut. and Gen.-Urin. Dis., 1890, p. 22; 
Graham, Canadian Med. Jour. Sci., June, 1879; Klotz, Am. Jour. Med. Sci., Dec, 
1891; Pemphigus Vegetans, Hyde, Jour. Cut. and Gen.-Urin. Dis., 1891, p. 412. 



DERMATITIS REPENS. 1 69 

Treatment is only palliative. No means have been ascertained 
whereby a recurrence of the blebs can be prevented.* 

DERMATITIS REPENS. 

Dermatitis repens is an inflammatory disease of the skin occur- 
ring usually upon the hands and characterized by the formation 
of vesicles or bullae extending on the periphery. 

The affection was supposed by Crocker, who first described it, 
to originate in a traumatism. This is not necessarily the case, 
however. The affection begins on the palmar surface of a 
finger or the palm of the hand in the form of a raised bleb under 
thick and soggy epidermis. This quickly spreads upon the per- 
iphery and after awhile the epidermis separates and opens in the 
center to pull off, leaving a raw, red surface which quickly be- 
comes a dry, red one. Meanwhile the edge of the lesion, push- 
ing on always in a centrifugal manner, is raised into a linear 
bullae containing a small amount of sero-pus. The finger, palm, 
entire tand, wrist and even forearm may be involved, the lesion 
skinning off the member like a glove. t 

The disease is probably an infective dermatitis. The treat- 
ment is purely local. 

IMPETIGO SIMPLEX. J 

Impetigo simplex is an inflammatory, pustular disease, char- 
acterized by one or more pin-head, pea- or finger-nail sized, dis- 
crete or confluent, circular or irregularly-shaped pustules, usually 
running an acute course, unattended as a rule by marked itching 
or burning. 

Impetigo simplex is the simplest form of impetigo, but is not 

* See Elliott, Jour. Cutau. Dis., 1895, xiii, p. 10; lb., 1899, xvii, p. 539; New 
York Med. Jour., April 21, 1900. Also Bowen, Jour. Cutan. Dis., 1898, xvi, p. 
253, and Wende, lb., 1902, xx, p. 537, lb., 1904, xxii. p. 14. 

t For an excellent picture see Stowers, B. Jour. Derm., 1896, viii, p. 1. 

X Some writers consider this form of impetigo as a variety of impetigo con- 
tagiosa, and include it under this head. They describe in addition what is called 
the impetigo of Bockhart, as being the true typical impetigo. Others, and my- 
self among them, consider Bockhart's impetigo as a folliculitis, and divide the 
true impetigos as in the text above. 



I70 DISEASES OF THE SKIN. 

at the present time by any means as common as impetigo con- 
tagiosa. When typical it shows itself in the form of lesions which 
are from the beginning pustules, firm, hard, raised and surrounded 
by a slight areola. The elevation is marked and the lesions 
may at times appear semi-globular. There is no central point, 
depression or umbilication. The pustules are grayish-white or 
yellowish in color. When mature the areola subsides, leaving 
the crusts rising direct from the skin. 

The pustules are discrete and, even when grouped together, 
do not show any tendency to coalesce. In number they vary 
from two or three to a dozen or more. They may occur upon 
any part of the body but are most common on the face, hands, 
fingers, feet, toes and lower extremities, and, sometimes upon 
the palms and soles. They are not as a rule attended by itch- 
ing or burning. They run an acute course, usually lasting a 
week or ten days. The crusts desiccate and drop off leaving 
reddish bases without pigmentation or scar. 

The affection is confined for the most part to children. It 
is, according to Duhring, from whom this description is taken, 
one of the rarer pustular manifestations. 

The chief interest in the diagnosis of impetigo simplex is its 
differentiation from impetigo contagiosa. The two affections 
resemble one another pretty closely but there are important 
clinical differences. The initial lesion in impetigo contagiosa 
is generally a vesico-pustule; in simple impetigo it is always a 
pustule. The lesion of impetigo contagiosa is remarkably super- 
ficial; that of impetigo simplex has a deeper seat and thicker walls. 
The pustule of impetigo contagiosa tends to flatten, and is often 
marked by umbilication; that of impetigo is raised and without 
central depression. 

From pustular eczema, impetigo simplex may be distinguished 
by the size and peculiar conformation of the pustules, these being 
large and prominent while those of eczema are small and not 
raised. In impetigo simplex the pustules are discrete while in 
eczema they tend to run together and form pustular patches. 
In impetigo there is little infiltration whereas, in eczema, infil- 



IMPETIGO CONTAGIOSA. 171 

tration is -a pathognomonic feature. In impetigo there is gener- 
ally no itching while in eczema the itching is marked. 

Impetigo simplex somewhat resembles ecthyma, but in the 
latter the pustules are flat, and are surrounded by extensive inflam- 
matory, hard bases. In impetigo they are elevated and generally 
have only a slight areola. In ecthyma the crusts are brownish 
or blackish in color, large, flat, and seated upon an excoriated 
or even ulcerated surface. Impetigo simplex occurs in the 
healthy and strong; ecthyma in the debilitated and cachectic. 

The treatment of impetigo is both prophylactic and curative. 
Being due to the implanation and growth of the Staphylococcus 
pyogenes every effort should be made to prevent the affection 
spreading and to destroy the parasite. Poultices rendered anti- 
septic by the addition of boric acid should be employed to remove 
the crusts, the entire surface of the body should be frequently 
cleansed with warm water and corrosive sublimate soap, and 
compresses wet with a saturated solution of boric acid or a solu- 
tion of bichloride of mercury 1-2000 should be applied to the 
lesions. If ulcers form beneath the crusts, these should be 
thoroughly cleansed by means of peroxide of hydrogen and 
dusted with europhen or aristol, and if an ointment is called for, 
one containing one of these substances or a strong boric acid 
ointment may be employed. 

Internal treatment is not usually required. 

IMPETIGO CONTAGIOSA. 

Impetigo contagiosa is an acute, inflammatory, contagious dis- 
ease, characterized by the formation of one or more superficial, 
discrete, roundish or ovalish, vesico-pustules or blebs, the size 
of a split pea or finger-nail, which pass into crusts. The erup- 
tion is commoner among infants and young children. Isolated, 
flat, or slightly raised vesicles are first seen, small in size at the 
beginning, but rapidly spreading on the periphery until they 
become like little blebs, with a thin, withered-looking, collapsed 
wall. The lesions are few in number. Usually they are dis- 



172 



DISEASES OF THE SKIN. 



crete, but sometimes two or more coalesce. They are most 
commonly found about the mouth, on the chin and nose, and on 
the hands. Crusts form in a few days, usually yellowish or 
straw-colored, and, as they dry, loosen at the edges, so as occasion- 
ally to look as if they had been stuck on the skin. The surface 




Fig. 



-Impetigo Contagiosa. 



beneath is moist and excoriated. The mucous membranes of 
the mouth and conjunctiva are occasionally invaded. The 
disease may extend from place to place by auto-inoculation. 
It runs its course in about ten days, tending to a spontaneous 
recovery. Sometimes, however, it runs an anomalous course. 



IMPETIGO CONTAGIOSA. 1 73 

The eruption here may consist of a few, even one or two, lesions 
only, about the nose and mouth with possibly one or two upon 
the fingers. In other cases it may be diffused over body and 
limbs resembling varicella or pemphigus. Occasionally circinate 
lesions are seen. Sometimes, instead of showing vesicles and 
blebs, small pustules appear from the first. 

The disease, although commoner amongst children, may occur 
in adults. Sometimes a group of cases of impetigo contagiosa 
of the beard region will occur among men who have been shaved 
by the same barber. Such cases, however, may commonly be 
traced to a child as the origin. 

Impetigo contagiosa is contagious and auto-inoculable. It is 
observed commonly in the lower ranks of life, although it may 
occur among the more refined. It is most common between the 
ages of two and ten. It is common among boys at school and foot- 
ball players. The disease is sometimes confounded with varicella 
by careless observers.* 

Impetigo contagiosa is due to a streptococcus. So soon as 
the vesicles are developed the Staphylococcus pyogenes aureus, 
which multiplies much more rapidly than the streptococcus, 
escapes and new foci of infection may occur which are caused by 
the invasion of the staphylococcus alone or chiefly. These sec- 
ondary lesions may take on the appearance of ordinary impetigo. 
The lesion is formed between the rete and the horny layer, this 
latter being the roof wall. There is a surrounding mild inflam 
mation. The underlying upper part of the corium displays acute 
inflammatory action with the usual features, The central portion 
of the lesion shows a large number of the staphylococcus pyogenes 
aureus, often streptococci as well as other cocci. 

Impetigo contagiosa is to be distinguished from pustular eczema, 
ecthyma, varicella and pemphigus. Eczema is distinguished by 
its greater variety of lesions, by the greater amount of infiltra- 

*See Stelwagon, Impetigo Contagiosa, its Individuality and Nature, Pliila., 
Med. News, Aug. 29, 1883; also Corlett, Cleveland Jour. 'Med., vol. iii, 1898, p. 
513; Allen (General, bullous), Trans. Am. Derm. Assn., 1896; Elliott, Jour. Cut. 
Dis., 1894, p. 194; Engman, " Impetigo contagiosa and its bacteriology," lb., 1901, 
p. 180, (with review and bacteriology). 



174 DISEASES OF THE SKIN 

tion,the itching, etc. From ecthyma the present disease is distin- 
guished by the occurrence of the inflammatory base and areola. 
Ecthyma is also more common on the legs. It also occurs chiefly 
among adults and in persons of depraved life and impaired vitality. 
The lesions of varicella are uniform and smaller, rarely larger 
than split peas, and more or less disseminated, with no tendency 
to grouping and with insignificant crusting. 

Although impetigo tends to rapid recovery its course is some- 
times prolonged by re-infections and, occasionally, by the con- 
current appearance of pediculosis capitis. 

The treatment of impetigo contagiosa is simple. Cleanli- 
ness is the basis. One of the medicated soaps, as EichofPs, 
or some other bichloride of mercury soap may be used to cleanse 
the surface, after which an ointment of ammoniated mercury, 
from 10 to 20 grains (0.65 to 1.35) to the ounce (32.) of cold cream 
should be gently rubbed in. 

ECTHYMA. 

Ecthyma is characterized by one or more pea or finger-nail 
sized, generally discrete, flat pustules situated upon an inflam- 
matory base, followed by yellowish or brownish crusts and pig- 
mentation, usually occurring in subjects in depraved health. 

The pustule of ecthyma appears a few hours after inoculation 
in the form of a red point. At the end of the second day a minute 
papule or pustule appears in the center of the red lesion. By 
the end of the third day the lesion has become acuminated in the 
center, and by the fourth day the ecthymatous pustule is fully 
developed in the form of a yellowish-white pustule the size of a 
large pin-head or small pea, surrounded by a red areola, at the 
edge of which the derma is somewhat infiltrated. By the fifth 
to the eighth day the pustule has increased considerably n size 
and has become flattened. By the ninth to the eleventh day a 
central crust has formed, around which is a whitish circle formed 
by the epidermis, which has been elevated by pus. Beyond 
this is the red areola. 



ECTHYMA. 



n 



At this point the lesion may cease to extend and may begin 
to heal, disappearing by the end of the fifteenth to the twentieth 
day, and leaving behind only a superficial, more or less pigmented 
cicatrix of a reddish-brown color, which tends gradually to 
disappear. Sometimes ulceration takes place under the crust. 
Occasionally the lesion of ecthyma extends more and more until 
it reaches an extraordinary size; the crust becomes thick, and 
gangrene may supervene. In broken-down subjects the affec- 
tion may become grave. Such forms of ecthyma are not infre- 
quently observed in our almshouses and prisons. 

Ecthyma is inoculable and auto-inoculable. 

Ecthyma usually attacks the lower limbs, although the shoulders 
and other parts may be attacked. It sometimes gives rise to 
lymphangitis and phlebitis. 

The subjective symptoms consist of slight itching or burning. 
Occasionally general symptoms of feverishness, etc., are observed. 

The cause of ecthyma is found in the introduction of pyogenic 
cocci, particularly streptococci into the skin. Filth and neglect 
arc the most common aggravations. In infants improper or in- 
sufficient diet and gastro-intestinal troubles and scrofula are 
predominant causes. 

The pustule of ecthyma differs from the pustule of eczema 
or the pustule of impetigo in the severity of the exudative process 
by which it is produced and in its limitation to the exact seat of 
external irritation. The process always begins as an inflamma- 
tion in the lower epidermal layers, fibrinous centrally and 
cedematous peripherally and which invades the dorma superfi- 
cially or deeply; minute intercellular cavities form, which melt 
together and filled with a fibrinous and purulent fluid. The 
fluid cavity involves the upper corium and exceptionally the 
entire corium. The pus usually contains staphylococci and 
streptococci. By the extension of the process to the corium 
there is an actual loss of tissue resulting in a cicatrix. 

Ecthyma is apt to be confounded with other pustular affec- 
tions, as pustular eczema, impetigo, dermatitis herpetiformis 
in some of its phases, and with the large pustular syphiloderm. 



176 DISEASES OF THE SKIN. 

A careful examination of the locality and character of the pustu- 
lation and the general condition of the patient will make the 
diagnosis easy. Syphiloderma pustulo-ulcerosum or "rupia" 
sometimes closely resembles ecthyma. The syphilitic eruption, 
however, is more deeply ulcerated, has a larger and more infiltrated 
base and is surmounted by a more abundant and raised crust. 
The general treatment of ecthyma consists in improving the 
health of the patient by proper hygiene and diet, and by the 
employment of tonics. The internal treatment should include 
rest, fresh air, bathing, cleanliness, with such nourishing food as 
milk, eggs, strong soups, etc. In a few cases the administration 
of alcohol and malt liquors is desirable, but in the majority 
of cases these should not be prescribed. In old persons tonics 
and remedies which will stimulate the action of the kidneys may 
be employed. The following formula, analogous to the well- 
known Basham's mixture, is useful: 

1^. Liq. ammoniae acetat., fjiiss ( 48. ) 

Acid acetic, dil., 9iv ( 5.20) 

Tinct. ferri chlor.. f3ij ( 8. ) 

Curacoae, f oiij (96. ) 

Aquae, Oss. (256. ) M. 

SlG. — A tablespoonful in water three times a day between meals. 

In younger persons we may prescribe a brisk purge with 
blue pill and colocynth, followed by an aperient tonic, as the 
"Mist, ferri acid." (See under Eczema). 

In broken-down cases pure tonics, as quinine, iron, etc., 
may follow these or be used in connection with them. 

The external treatment of ecthyma is essentially antiseptic 
and parasiticide. Since ecthyma is probably due to infection, 
the first thing to do is to suppress this factor, and next to prevent 
the propagation of the disease by scratching and auto-inoculation. 
The crusts, if numerous, are to be removed by a bath, preferably 
containing the sulphuret of potassium or by enveloping the 
parts in a rubber cloth or by the use of starch poultices con- 
taining boric acid (see Eczema). The parts are then disinfected 
by sublimate soap, or by means of carbolized lotions or a 1 to 



IMPETIGO HERPETIFORMIS. 1 77 

iooo solution of bichloride of mercury. The lesions are sub- 
sequently dressed with ointments containing iodoform, europhen 
or other antiseptics. 

IMPETIGO HERPETIFORMIS. 

Impetigo her pet i form is is a rare affection of the skin occur- 
ring in pregnant females, characterized at first by the appearance 
of superficial, miliary pustules, the contents at first opaque 
and later yellowish-green in color. Successive pustules form 
during the course of the disease, having a marked tendency to 
form groups. The lesions are surrounded by a red areola, and 
rest upon an inflamed base. A dirty, brown crust finally forms 
upon the center of the fully developed pustule, while a single, 
double, or even triple ring of new lesions appear, surrounding the 
original one, which follow the same course. 

The lesions originally appear at isolated points, especially 
the fold of the groin, the umbilicus, the breasts, and axillae, 
but gradually spread and coalesce until large areas become 
affected. When the crusts become detached and fall off, the 
underlying skin is found red and covered with fresh epidermis, 
or moist, weeping, infiltrated, and covered with numerous 
papules. Sometimes the mucous membranes are involved, 
there are symptoms of fever and general disturbance, with a 
fatal result in most cases, either in the course of the first attack, 
or in a second one occurring during a subsequent pregnancy. 
The affection is an infection and probably septicemic in char- 
acter. 

Most cases reported have been observed in Vienna. Heitzmann, how- 
ever. Archives of Dermatology, 1878, p. 37, and Fordyce. Jour. Cutan. Dis., 
1897, p. 495, have reported cases occurring in this country. 

FURUNCULUS. 

Furuncle, commonly known as "boil," is a deep-seated, in- 
flammatory disease, characterized by one or more variously-sized, 
circumscribed, more or less acuminated, firm, painful formations, 
usually terminating in central suppuration. 



178 DISEASES OF THE SKIN. 

Boils may occur singly, or in numbers. When they occur 
in successive crops the condition is known as furunculosis. 
The lesion, at first a small, ill-defined, reddish spot, situated 
in the true skin, and tender and painful from the first, soon 
becomes larger, slightly elevated, and shows a tendency to 
suppurate about its center. It arrives at maturity in a week 
or ten days, and is then a slightly-raised, rounded, or pointed 
formation, with a suppurating center, called the core. At times 
no center of suppuration forms; it is then called a "blind boil." 
The size of a boil may vary from that of a split pea to a large 
coin. Its color is dusky red; it usually gives rise to a dull, throb- 
bing pain, increasing in intensity until suppuration takes place, 
and then subsiding. 

Though the boil may attack any part of the body, its favorite 
seats are the face, ears, back of the neck, shoulders, axillae, but- 
tocks, perineum, scrotum, labia, and legs. Sometimes it is ac- 
companied by some general constitutional disturbance. Neigh- 
boring glands may be sympathetically enlarged. 

Boils sometimes occur as complications or sequelae of other 
diseases, e. g., eczema. An acute attack of eczema often winds 
up with a crop of boils. Sometimes the boil tends to return 
again and again in about the same spot. 

The remote causes giving rise to boils are various and some- 
times obscure. Often they are the result of a low and depraved 
condition of the system. General debility, overwork of a mental 
sort, excessive bodily fatigue, nervous depression, improper 
food, and irregularity of the functions of the body are among 
the common causes of boils. They are sometimes encountered, 
however, in persons apparently enjoying perfect health, and 
given to active and varied out-door exercise and amusement. 
The boils to which the hydropathist points with pride, as evidence 
that the peccant humors are being "driven out," are in reality 
the evil result of erroneous hygiene and regimen. Boils not 
unfrequently occur in the course of other diseases, as diabetes, 
chlorosis, fevers, uraemia, and septic pyaemia. Occasionally 
certain atmospheric conditions, prevailing chiefly in the spring 



FURUNCULUS. 179 

and autumn, seem influential in determining the occurrence of 
boils, which at times appear to prevail as a sort of epidemic. 

Boils have their immediate origin in the invasion of the sebace- 
ous gland, hair follicle, or, possibly in some cases, a sweat gland by 
the staphylococcus pyogenes aureus. The core or central slough 
of a boil is composed of pus and the glandular and perifollicular 
tissue in which it had its origin. The intense zone of inflam- 
matory deposit around the center, by shutting off the vascular 
supply, results, along with the liquefying action of the cocci and 
leukocytes, in the breaking down of the central portion and the 
production of the core mass. Most boils begin as an impetigo 
lesion or sycosiform pustule, the cocci penetrating and spread- 
ing from this point. 

The diagnosis of furuncle is generally easy, the affection being 
familiar to every one. From anthrax, or carbuncle, it differs 
in only having one point of suppuration — the core — while the 
former has several or many such centers. The furuncle also 
is inclined to be rounded or acuminate; carbuncle is flat. Furun- 
cle is small; carbuncle varies in size, from half an inch to three or 
four or more inches in diameter; furuncle is tender to the touch; 
carbuncle, though spontaneously painful, is not tender. Boils 
generally occur in numbers; carbuncle is commonly single. 
Now and then certain pustular syphilodermata resemble boils, 
but their indolence, painlessness, and darker, duskier color, 
together with the chronic, slow course which they run when 
unaffected by treatment, will rarely give rise to difficulty in the 
diagnosis. 

The successful treatment of boils is, at times, by no means 
easy. Each case demands careful study, with the view, if 
possible, of ascertaining the cause at work, and obviating this, 
if it can be done. The various functions of the body are to be 
carefully regulated. The diet should be of good quality and 
varied. Wine and malt liquors may be prescribed in rare cases, 
and when the patient is not accustomed to their use. The 
regimen should be moderate and conducive to the general im- 
provement of the system. Fresh air and out-door exercise are 



l8o DISEASES OF THE SKIN. 

to be urged in most cases. Tonics are very often called for. 
Quinine in considerable doses, as much as fifteen grains (i) per 
diem, and iron, alone or with strychina, may be given. Cod-liver 
oil is also suitable in some cases. The "Mistura ferri acid.," 
often prescribed in eczema, is useful at times. 

Arsenic, alone or in combination with iron, is sometimes of 
value. The hypophosphites are also frequently prescribed to 
advantage. Fresh brewers' yeast in tablespoonful doses three 
times daily is an old remedy recently revived. Such are the 
remedies most usually relied upon in the treatment of furuncu- 
losis. No one can be recommended as a specific; what will do 
good in one case may fail in another. 

Locally, one method of aborting the forming boil may be 
recommended; it is, when a hair is growing out of the center 
of the boil to pull it out. This will sometimes check the further 
development of the boil. A fine-pointed stick dipped in ichthyol 
should be thrust into the follicle immediately after depilation. 
The application of cold, in the form of powdered ice poultices, 
is recommended by Hebra. The use of caustics, as a red-hot 
needle, nitrate of silver, or a mixture of equal parts carbolic 
acid and glycerine, nitric acid, acid nitrate of mercury (or a 
pointed stick of caustic potash), may be used to the apex of the 
forming boil. Salicylic acid- may be applied in the form of a 
plaster: 

1$. Acid salicylic, 3ij (8.) 

Emplast. saponat., §ij (64.) 

Emplast. diachyli, 5j- (32.) M. 

This is to be applied spread upon a cloth as an ordinary plaster. 

When the boil begins to discharge, a hole is cut in the plaster, 
to permit the escape of the products of suppuration. 

A ten per cent, salicylic acid ointment well rubbed into the 
skin may be employed instead. 

Ichthyol may be employed, rubbed into the skin in full strength. 
When suppuration is once established the boil should be opened 
and thoroughly scraped out with a sharp spoon. To prevent 
the transmission of infection the parts about the boil should be 



CARBUNCULUS. l8l 

shaved when there is hair and the skin kept clean by frequent 
washing with the tincture of green soap or by the use of some 
antiseptic soap. 

Peroxide of hydrogen forms one of the best applications to fol- 
low incision and scraping. It is said that under this application 
the pain ceases, and the separation of the core takes place pain- 
lessly. Incisions should not be employed at any stage unless 
absolutely required, and then only with antiseptic precautions 
and subsequent antiseptic dressings. An incision sometimes 
carries the virus to new points. 

The prognosis of furuncle is generally favorable. Occurring 
in broken down persons in great and increasing numbers a very 
great deterioration of the health ensues. In young infants espec- 
ially where there is a tuberculous infection the prognosis of mul- 
tiple furunuculosis is grave. 

CARBUNCULUS. 

Carbuncle is a hard, more or less circumscribed, dark red, 
painful, deep-seated inflammation of the skin and subcutaneous 
connective tissue, variable as to size, terminating in a slough. 
Carbuncle is usually accompanied by a good deal of constitu- 
tional disturbance. It is ushered in by a chill followed by fever. 
The skin over the affected part becomes hot and painful, and a 
firm, fiat, more or less sharply circumscribed inflammation, of 
a somewhat dusky red hue, forms, which is deeply seated in the 
tissues. It is painful, with commonly more or less of a burning 
sensation. The symptoms become gradually more marked 
during ten days to two weeks, when the tissues begin to break 
down and soften, and the skin becomes gangrenous. Perfora- 
tions appear at various points, either filled with tough, yellow, 
fibrous cores, or hollow; and from these issues a yellow, sanious 
fluid. The surface soon assumes a cribriform or sieve-like 
appearance, which is very characteristic. Unless the carbuncle 
is small the whole skin covering it usually sloughs sooner or 
later, leaving a large open ulcer, healing slowly. 

The duration of carbuncle is usually from four to six weeks, 



102 DISEASES OF THE SKIN. 

though its course depends somewhat on the age and strength of 
the patient. It is usually single, and its favorite seats are on the 
back of the neck, shoulders, back and buttocks. The hairy 
scalp, the front of the abdomen, and the lips are all looked upon 
as situations of especial danger. Carbuncle attacking the upper 
lip is believed to be an especially fatal variety. It is apt to be 
found in young persons, runs an acute and rapid progress and 
is apt to lead to a fatal result from pyaemia. This form of disease 
is by some believed to be a variety of malignant pustule. Against 
this view it may be stated that pain and the presence of pus in 
considerable quantities are characteristic of this form of disease, 
while both of these are, to a great extent, absent in malignant 
pustule. (Cameron.) In elderly persons carbuncle is a serious 
disease, and when extensive is apt to terminate fatally. Boils 
often appear about the borders of carbuncle. The affection some- 
times occurs in connection with diabetes and Bright's disease. 

The cause of carbuncle is the invasion of the part by the same 
staphylococcus which gives rise to furuncles. The disease is 
not, however, a group of boils, but a much more deeply-seated 
and serious affection. 

The inflammation starts simultaneously from numerous points, 
from the hair follicles, sebaceous and possibly from the sweat 
glands; the inflammatory centers break down, and the pus 
finds its way to the surface; finally, the process ends in gangrene 
of a part or of the whole area. The pyogenic micro-organisms 
are present in abundance in the tissues. The inflammation 
may also, in some cases, start deeply down from some point or 
points in the subcutaneous tissue. It is probable that the 
intense inflammation shuts off the vascular circulation and thus 
produces necrosis of the tissues. 

Carbuncle is distinguished from furuncle by its size, flatness, 
multiple points of suppuration, and extensive slough. From 
erysipelas, which it sometimes resembles in its early stages, 
its circumscribed outline will soon distinguish it. 

The general treatment of carbuncle should be strongly sup- 
porting. Nourishing food must be freely given, and in some 



PHLEGMONA DIFFUSA. 1 83 

cases stimulants, although sparingly and with caution. The best 
opinion is opposed to the excessive and indiscriminate use of 
stimulants formerly customary. Tincture of iron and quinine 
are the best medicines. The latter should be given in sixteen 
to twenty-five grain doses once daily. Anodynes should be 
given freely when required to procure rest at night. Fresh 
air and exercise, when these can be taken, are important factors. 
When the carbuncle is tense and hard, antiseptic poultices, prefer- 
ably made with a 1-2000 solution of corrosive sublimate, and 
deep, cruciform incisions for relief followed by scraping may be 
resorted to when required, and when practiced with the addition 
of thorough antisepsis and the application of strong parasiticide 
remedies is perhaps the best procedure. 

The parts should be kept clean, washed frequently with a 
weak carbolic solution, and the slough removed as rapidly as 
possible, so as to leave a minimal amount of diseased tissue in 
contact with the springing granulations. At the earliest possible 
moment after suppuration has commenced the carbuncle should 
be freely opened and the dead tissue scraped out thoroughly, 
and afterwards the cavity packed with an antiseptic, as iodoform. 
Antisepsis lies at the foundation of all modern local treatment 
of carbuncle. The first thing to do is to get at the noxious 
germs and destroy them, remembering always not to use such 
vigorous treatment as will further inflame the tissues. To the 
antiseptic treatment should be added such soothing remedies 
as are admissible. 

Sometimes the thermo-cautery is used to remove portions of 
the diseased tissues. 

When the ulcer begins to granulate it must be encouraged to 
heal. The prognosis should be extremely guarded. Death 
may occur from exhaustion, pyaemia, collapse, or, when the scalp 
is affected, by inflammation and effusion within the cranium. 

PHLEGMONA DIFFUSA. 

Phlegmona diffusa or phlegmonous cellulitis is a more or less extensive in- 
flammation of the cutaneous or subcutaneous tissues which is similar to or 
closely allied to cellulitis and to erysipelas. 



184 DISEASES OF THE SKIN. 

After malaise and rigors a febrile action ensues with sharp or dull pain at 
the site of the disease. The first appearance is of a hard lumpiness or infil- 
tration, somewhat deeply seated and attended by swelling and cedema, which 
may involve a considerable area. In the course of five or ten days some soft- 
ening occurs with tendency to discharge or retrogression and disappearance 
of the swelling. Sometimes a necrosis takes place or burrowing of pus under 
the tissues. 

The disease is probably due to infection by the erysipelas coccus and pyo- 
genic staphylococcus. The disease may be mild or severe and rapidly fatal. 
The treatment is that of erysipelas with local surgical measures as required. 

DISSECTION WOUNDS. 

These may be due to irritative secretions from dead bodies, pus cocci, or 
tubercle bacilli. The infections from the latter will be found described under 
tubercle of the skin. 

Post-mortem pustule begins by an abrasion of the skin rarely noticed and 
quickly followed by the appearance of a small, red, itchy spot, which rapidly 
develops into a vesico -pustule or pustule, having a dull, red inflammatory base. 
The pustule dries or breaks, then fills up again, etc. If removed a small 
ulcer appears beneath. The lesion is more or less painful, surrounded by 
swelling and lymphatic involvement — septic infection sometimes occurs. 

Post-mortem pustule occurs in the dissection room or, rarely, among 
butchers. The essential (bacterial) cause is not known. 

Treatment consists in opening the pustule, removing the crust, cleansing 
with hydrogen dioxide, and the use of wet, antiseptic, corrosive sublimate dress- 
ings. Or an antiseptic powder as iodoform or europhen may be used. 

EQUINIA. 

Equinia, glanders or farcy, is an inoculable, acute or chronic disease of ma- 
lignant type, derived from the horse, mule or ass, and characterized by grave 
constitutional symptoms, inflammations of the nasal and respiratory passages, 
and a vesico -pustular, papulo -pustular or deap-seated tubercular or nodular 
ulcerative eruption. 

The disease may gain access to the body through some break in the skin 
or of the mucous membrane of the eye, mouth, etc. After a time malaise, 
fever, etc., set in and a phlegmonous inflammation or pustule may show itself 
at the site of inoculation, which later breaks down into an unhealthy ulcer 
tending to spread. Inoculation of the eye or nose may lead to destructive 
ulceration of the part. Other pustules may arise, deep-seated nodules, the 
so-called farcy buds, may appear and the lymph glands and channels may be- 
come thickened. The mucous membrane of the nose is peculiarly apt to be 
involved with ulceration and profuse thick mucoid discharge. In acute cases 



PUSTULA MALIGNA. 1 85 

the febrile symptoms continue. Occasionally sepsis may supervene with 
fatal issue. 

The disease is rare in this country. It is usually contracted from horses 
and occurs among those who care for those animals. It may be transmitted 
from man to man. 

Equinia is caused by the presence of the glanders bacillus {Bacillus mallei), 
found in all lesions, the blood and other fluids and tissues. The lesions are 
made up of round -celled granulation tissue which breaks down easily. 

The diagnosis is made from the presence of nasal discharge, cutaneous and 
mucous membrane lesions occurring in combination. Microscopic examina- 
tion for the characteristic bacillus should be made in doubtful cases. 

The treatment is empirical; the prognosis in most cases unfavorable. 

PUSTULA MALIGNA. 

Malignant pustule, or anthrax, is a furuncle- or carbuncle-like gangrenous 
lesion resulting from inoculation with the bacillus anthracis, and usually ac- 
companied with constitutional symptoms of more or less gravity. 

The disease in man is of rare occurrence and results from inoculation from 
some animal, usually one of the horned domestic animals. About twelve 
hours to three days after the introduction of the virus a flea-bite -like macule 
is observed at the affected point, usually the back of the hand, cheek, or some 
other exposed part. In twelve to fifteen hours this is succeeded by an inflam- 
matory and pruritic papule, which is transformed rapidly into a flaccid ves- 
icle filled with bloody serum and surmounting a firm, indurated base; or a 
larger blood-filled bleb develops reposing upon a somewhat painful, engorged, 
and often densely indurated base, involving extensively the subcutaneous 
tissue. One or more lesions may follow in the surrounding integument, coal- 
escence of which lesions produces a large, angry, cedematous, and often gan- 
grenous ulcer with a reddish areola. The area involved may be from coin to 
palm size. The lymphatic vessels and ganglia become inflamed and often 
suppurate and metastatic abscesses may ensue. High fever, septic absorption 
and death follows in severe cases. 

The disease is induced by the inoculation of the Bacillus anthracis, the same 
poison which causes the splenic fever, Texas fever or charbon in cattle. The 
germs are found everywhere in the blood and tissues. 

The diagnosis of malignant pustule is made from the characteristic lesions 
of a central eschar, with. areola or crown of vesicles and indurated base, es- 
pecially occurring in one liable to contact with animals. Poisoned wounds, 
facial chancre and the pustular eruptions caused by contact with the dead 
bodies of men and animals are to be excluded. 

The disease is a serious one, but with early diagnosis and prompt treat- 



1 86 DISEASES OF THE SKIN. 

ment the danger is lessened. Excision of the entire area is to be promptly 
practiced under strict antiseptic precautions to prevent reinfection. Subse- 
quently the ordinary treatment of open wounds. Sodium sulphite or hypo- 
sulphite with quinine should be given internally, with alcohol, carbonate of 
ammonium, etc., if required. 

ERYSIPELAS. 

Erysipelas is a specific inflammation of the skin and subcu- 
taneous tissue, most commonly of the face, characterized by 
shining redness, swelling, oedema, heat, and a tendency, in some 
cases, to vesicular and bleb-formation, and accompanied by 
more or less febrile disturbance. 

The outbreak, in average cases, is preceded by a period of 
malaise, chilliness, nausea lasting a few hours to several days, 
and rapidly followed by .the appearance of the cutaneous eruption. 
This appears at a place where there has been a break in the con- 
tinuity of the skin in the form of an area of disease, from a dime 
to a silver dollar size, elevated, swollen, red and shining, with a 
glazed appearance. There is a feeling of burning, often some 
tenderness, and sometimes more or less itching. The border 
is sharply defined, elevated, and bright-red, it spreads gradually 
or rapidly by peripheral extension, and in some cases there may 
arise new points of infection near by, spread and merge into 
each other. In the course of several days to a week the disease 
has usually reached its acme, and may then cover a great part of 
the face or the entire region. In most cases the skin is dark 
red, swollen, tense, and shining, but sometimes there are vesicles 
or pustules or exceptionally the part may be partially undermined 
with serous effusion. Sloughing may ensue in rare instances. 

When the erysipelas involves a limb streaks of red along the 
lines of the lymphatics may be noticed. The constitutional 
symptoms vary and the temperature may be elevated from one 
or two to several degrees above the normal. After remaining a 
few days stationary the process begins to subside, the swelling 
abates, the color changes to brownish-red, yellowish and whitish 
shades and at the end of ten days to a few weeks the disease is 
well. Desquamation to a greater or less extent follows. 



ERYSIPELAS. 1 87 

Considerable variation from the type occurs in some cases. 
Thus the disease may light up in one place while healing in 
another, or it may wander from place to place over the surface. 

Erysipelas is both contagious and infectious. The essential 
cause is believed to be the streptococcus of Fehleisen and possibly 
other organisms. The disease finds entry by a prick or abrasion 
sometimes so minute as to escape detection. A not unfrequent 
point of infection, says Stelwagon, from whom this description 
of the disease is taken, is a sycosiform inflammation just inside 
the nostril. 

As predisposing causes may be mentioned, a poor condition 
of .the health, debility, alcoholism, in fact anything which de- 
presses or weakens the vital forces and lessens the resisting 
power of the organism. 

The specific germ is the sole pathogenetic factor in the 
disease. One attack does not protect against a subsequent one, 
in fact it makes such an attack more likely, probably because some 
of the germs remain latent in the skin. Erysipelas is an infectious 
dermatitis. The corium is invaded in severe cases by the strep- 
tococci and this invasion may extend down into the subcutaneous 
tissue. In rare instances streptococci have been observed in 
various organs. 

The diagnosis of erysipelas is usually not difficult. The char- 
acter of the onset, the shining redness, the swelling, the sharply 
defined elevated border, and the accompanying constitutional 
disturbance are all pathognomonic. Phlegmona diffusa, the ery- 
themata, acute eczema and dermatitis are most apt to be mis- 
taken for erysipelas and vice versa. Some form of ivy poison- 
ing and iodoform dermatitis also resemble erysipelas. 

Erysipelas is not often a fatal disease. Occurring in debilitated 
persons, however, or after an operation the prognosis is more 
grave. 

The constitutional treatment of erysipelas should be of a tonic, 
stimulating character with nourishing food, chiefly milk, in severe 
cases. Tincture of iron in doses of 15 to 40 minims (1-2.65), 
quinine, 2-3 grains (0.13-0.2), with moderate doses of strychnia 



IOO DISEASES OF THE SKIN. 

are called for. Locally ichthyol in lotions of 10 to 20 per cent, 
in water or ointment forms the best application. Antiseptics 
as carbolic acid, boric acid, resorcin, etc., in solutions of various 
strength from one per cent, upward may also be used. Painting 
with strong nitrate of silver solution or tincture of iodine in a band 
just beyond the spreading border of the disease sometimes arrests 
its progress. 

ERYSIPELOID. 

Erysipeloid is a rare skin affection somewhat resembling 
erysipelas but lacking the more striking local appearances and 
the constitutional symptoms which characterize the latter. 

The affection is observed in those who handle putrid meats 
or fish, such as butchers, fish-dealers, poultry-dealers, etc., or 
from crab-bites (Gilchrist). The disease starts from some fissure 
or abrasion in the skin. It consists at first of a dull red or purp- 
lish spot or zone, scarcely elevated, which tends to spread; as 
it spreads the first part involved usually clears up. If infection 
takes place at several points, a ring-like or festooned appearance 
may result. The advancing border of the erythema is sharply 
defined against the surrounding skin, and is commonly purplish 
or even livid in color. There may be some swelling or puffiness. 
Itching and burning are sometimes marked. Its progress is slow 
and sometimes only a small area as a single finger may be in- 
volved. Subsiding, the color changes to a yellowish and finally 
disappears. There is no scaliness. 

The disease is said to be due to an organism found in dead 
or decomposing animal matter and probably of the family of 
cladothrix. Gilchrist, however, believes it due to a ferment. 
The affection is to be distinguished from erysipelas and ring- 
worm. 

The treatment is the same as that of erysipelas. Ichthyol 
probably forms the best local application.* 

* Morrant Baker first described the disease under the name ''Erythema Ser- 
pens," St. Bartholomew' s Hosp. Reports, ix, 1873, p. 198. In this country Elliott, 
Jour. Cutan. Dis., 1888, p. 12, and Gilchrist, New York Med. Rec, 1896, vol. 
xlix, p. 783, and Jour. Cutan. Dis., 1904, p. 507, have given the best account of 
the affection. 



DERMATITIS GANGRENOSA INFANTUM. 1 89 

DERMATITIS GANGRENOSA INFANTUM.* 

Dermatitis gangrenosa infantum, erythema gangrenosum or 
varicella gangrenosa is a gangrenous affection observed in infants 
and children, arising spontaneously or following other vesicular 
or pustular eruptions, more especially varicella and vaccinia. 

The eruption often follows varicella. The vesicles instead 
of drying up in the usual manner become crusted centrally, often 
with a pustular border and surrounded by a red areola. Ulcer- 
ation begins beneath the crust and results in an eschar. Contig- 
uous lesions may become confluent and form an irregular ulcer 
of some size and depth. Cicatrices, of course, result. The disease 
has been known to follow vaccinia, taking its starting point in 
the neighborhood of the vaccine vesicle. Cases arising spon- 
taneously generally show first upon the buttocks as small pap- 
ulopustules. Cases vary in gravity, some being slight, others of 
ominous severity with fever vomiting, etc. The disease is rare 
and chiefly met with in debilitated infants. The treatment is 
tonic with antiseptic dressings. 

MULTIPLE GANGRENE OF THE SKIN IN ADULTS. 

Under this head are included cases variously described as 
spontaneous gangrene of the skin, disseminated gangrene, 
hysteric gangrene and gangrenous zoster. 

Some cases of apparently spontaneous gangrene, occurring in 
hysterical girls and others, are undoubtedly factitious in origin. 
Others, and such are many of the cases reported as hysterical 
gangrene, are produced in part by unconscious movements 
of the patient and in part are apparently the result of angioneu- 
rotic spasm. 

Still other cases as those following burns and injuries seem to 
be trophoneurotic in character. 

The typical lesion of hysterical gangrene is an oblong ery- 
thematous patch looking like an urticarial lesion or as if result - 

* See Hutchinson on Gangrenous Eruptions in Connection wilh Vaccination and 
Chicken-pox, Lond. Med. Chir.Soc. Trans., 1882, p. 1. Elliott, Dermatitis Gan- 
grenosa Infantum, A T . Y. Med. Rec, May 16, 1891. 



190 



DISEASES OF THE SKIN. 



ing from rubbing the skin. The epidermis soon loosens from 
the patch, a superficial slough forms, dries, and is cast off as a 
crust. There is no ulceration. 




Fig. 



29. — Multiple Gangrene of the Skin (Neurotic Excoriations or 
Hysterical Gangrene. (After Doutrelpont.) 



Multiple gangrene not hysterical in origin follows fevers 
as typhoid, malaria, scarlet fever and measles.* 

* For a fuller description of this form of gangrene see Stelwagon and Hyde 
and Montgomery. Cf. also Hartzel, Trans. Coll. Phys. Phila., 1898, p. 1; also 
C. J. White, Recurrent Hysterical Dermatitis, Jour. Cut. Dis., 1903, p. 415. For 
a discussion of hysterical gangrene see the author's papers, "The Hysterical 
Neuroses of the Skin." Am. Jour. Med. Set., 1897, cxiv, p. 64, and Jour. Cutan. 
Dis., xxi, p. 403. The picture given in the text is from Doutrelpont "neber ein 
Fall von acute multiple Hautgangrene," Arch. / Derm, v Syph., vol. xiii, 1880 
p. 179. 



DIABETIC GANGRENE. 191 

DIABETIC GANGRENE. 

Gangrene occurring in connection with diabetes may show 
itself spontaneously without previous injury to the affected skin, 
or it may arise at the seat of a slight injury or at the seat of the 
skin affections common in such subjects. In cases arising spon- 
taneously there may be loss of sensation, neuralgic pain, cold- 
ness, or intermittent flushing or Avidity. Blebs and vesicles 
may then ensue, the parts becoming dark colored and death of 
the part ensuing. 

In diabetic gangrene following traumatism the disease may 
spread and involve deeper tissues. Parts exposed to knocks and 
injuries, as the legs and hands, especially the former, are liable 
to be attacked. 

The patches in diabetic gangrene are rounded, irregular, or 
even serpiginous. Constitutional disturbance and subsequently 
septic symptoms sometimes occur. 

Diabetic gangrene is very rare. It is a serious symptom and 
renders the prognosis of the disease much less favorable.* 

SYMMETRIC GANGRENE. 

Symmetric gangrene is an affection, usually of the extremities, 
of probably trophic nature, characterized by local ishaemia 
and asphyxia which may terminate in gangrene of the skin and 
underlying tissue. | 

The extremities, such as fingers, toes, ears and nose are usually 
affected. It is generally symmetric. The first symptoms are 
coldness and paleness of the parts, with pain and numbness. 
Later the parts become dark red, livid and bluish and some- 
times swollen, with, not unfrequently, tenderness and shooting 
pains. The process may retrocede at this point to recur later 

* See Kaposi, " Hautkrankheiten der Diabeten," Wien. Med. Wochens., 1884, 
Xos. 1, 2, 3 and 4. C. W. Allen, Med. News, Oct. 24, 1896. Morrow, "The 
Cutaneous Manifestations to Diabetes," Med. Record, April 11, 1896. 

t The affection was first carefully described by Reynaud in 1862 and hence is 
usually known bv his name. 



192 DISEASES OF THE SKIN. 

or sometimes it does not go beyond this stage. Finally, however, 
in marked cases it goes on to dry gangrene or if the fingers or 
toes are affected the extremities become withered. In other 
cases more extensive gangrene occurs and the affected parts 
separate as a slough. 

The affection has been ascribed to various agencies; cold, 
exposure, general disturbance of nutrition, a sequence or asso- 
ciated condition of severe systemic fever or disease, nephritic 
disorders and various neuroses. It is a vaso-motor nutritive 
disturbance. There is first a contraction of the arterioles and 
capillaries, followed by dilatation and paralysis of the vessels. 

The prognosis varies with the severity of the case. Numerous 
cases of vaso-motor disturbance stopping just short of the pro- 
duction of gangrene are met with, and not unfrequently such 
cases go just over the boundary. But severe and extensive cases 
of symmetrical gangrene are apt to eventuate fatally. 

The treatment must vary with the underlying cause. In 
mild cases where actual gangrene has not yet occurred I have 
found nitroglycerine of value. Amyl nitrite may also be used. 
The galvanic current, frictions with cold and stimulating applic- 
ations may also be employed. 

DERMATITIS CALORICA. 

Dermatitis calorica includes dermatitis resulting from both 
heat and cold. As the former of these varieties under the title 
"Burns" is fully described in all text-books of surgery, I shall 
omit its description here and proceed to the consideration of: 

DERMATITIS CONGELATIONIS. 

The inflammations of the skin produced by cold resemble, 
in many respects, those produced by heat, only, unlike burns, 
their course is slow. In addition, a certain morbid predisposi- 
tion on the part of the patient is a necessary condition of their 
occurrence. The occurrence of chilblains does not necessarily 
depend on the influence of extreme cold; indeed, the affection 



DERMATITIS CONGELATIONIS. 1 93 

is said to be commoner in warm than in cold countries, and may 
occur at a temperature not below 32 F. Anaemic and chlorotic 
persons are more apt to be the subjects of the affection. 

The erythematous form of chilblain shows itself in the form 
of circumscribed patches, of a livid, red color and somewhat 
tubercular character, the color disappearing under pressure of 
the ringer. The lesions itch and burn painfully. They occur 
most commonly upon the ringers and toes, but may appear also 
on the ears, nose, or other parts of the face, or, indeed, on any 
part of the body which is exposed to cold. Their course is 
essentially chronic; usually they do not change in appearance 
but sometimes become hard and infiltrated, while at other times, 
under the influence of pressure or rubbing, as of the shoe, or of 
scratching, a bleb or pustule forms. The pain is then considerably 
increased, especially when the bulla or pustule bursts and leaves 
an ulcer. These changes, however, frequently lead to the cure 
of the affection, which might otherwise have lingered on in- 
definitely. 

The bullous form of chilblain is formed under the influence 
of a more intense degree of cold, and is characterized by the 
formation of watery or sero-sanguinolent blebs, the size of hazel- 
nuts or goose-eggs. If they are not punctured they undergo 
no change for some time, but at last break, after having effected 
considerable destruction of tissue, the bones even of the feet 
and hands being in extreme cases occasionally laid bare and 
exfoliating. 

The escharotic chilblain is a still more extreme degree of the 
same process, sloughs forming, which may be cast off without 
further effect, or which may poison the blood with fatal result.* 

Lupus erythematosus may sometimes be mistaken for chil- 
blain, and, in fact, occasionally follows it. For the diagnosis 
reference may be made to the general features described under 
its former head. 

The treatment of chilblain is, first of all, in the way of pre- 

* Chilblain has been supposed to bear some relation to tuberculosis, and is 
undoubtedly related to Reynaud's disease and to the "glossy skin" of Weir 
Mitchell and other writers. 
13 



194 DISEASES OF THE SKIN. 

vention. A sufferer from this disease must not expect to be 
cured while continuing to expose himself to the influences which 
produced it. Warm and sufficient clothing, protection of the 
hands and feet, and in cases where the general system is below 
par, such medication and hygiene as will improve this condition ; 
such are the points to which attention must first be paid. In 
mild acute chilblain, rest, in the horizontal position, frictions 
with cold water or snow, and astringent sedative lotions, as 
lead- water, lotion of grindelia robusta (see Dermatitis venenata), 
or opiate washes, may be prescribed. In the more chronic forms 
of erythematous chilblain stimulant applications are called for. 
When unbroken the lesions may be painted with tincture of 
iodine, or, better, with oil of peppermint, pure or mixed with 
one to six parts of glycerine. The following pigment is con- 
venient of application: 

ty. Tinct. iodini, 9j ( 1.33) 

Athens, f3iiss (10. ) 

Collodii, foj- (32. ) M. 

SiG. — Apply with a camel's-hair brush. 

When the lesions are broken, or in any case, the following 
forms an excellent application: 

1$. Terebinth Venetian, 3iij (12.) 

Ol. ricini, f 3iss ( 6.) 

Collodii, ad oj (32.) M. 

SiG. — Apply with a brush as often as required to shield the chilblain from 
the air. 

The following ointment may also be employed: 

J$. Plumbi acetat., ohss (10.) 

Ol. rapi (Colza), fg j (32.) 

Vitel. ovi., j (3.) 

Cerae flavse, 3iss. • ( 6.) M. 

Lassar recommends: 

1^. Acid, carbolic, gr. xvss ( 1.08) 

Ung. diachyli, 

Lanolini, aa 3v (20. ) 

Ol. amygdalae, 3iiss (10. ) 

Ol. lavandulae, gtt. xx. ( 1.33) M. 



DERMATITIS VENENATA. 195 

Liniment of aconite may be used, but with caution. 

Carbolized cosmoline sometimes relieves the burning and itching. 

The severer forms of dermatitis from cold belong rather 
to the province of the surgeon than the physician. When opera- 
tive interference is not demanded, they are to be treated in a 
similar manner to burns of the like gravity. 

DERMATITIS VENENATA.* 

Dermatitis venenata includes the various eruptions produced 
by the local effect of toxic agents. Chief among these is the 
inflammation caused by contact with poisonous plants, of which 
the poison ivy and the poison oak are best known. 

The effect of the rhus vine and oak varies greatly with the 
individual. Some persons are so susceptible that they cannot 
pass to the windward of the vines, or be exposed to the smoke 
from their burning, without suffering severely, while others 
can handle them with impunity. The severity of the eruption 
may also vary from the production of a few vesicles to a very 
severe eruption, and even death is said to have been caused in 
several reported cases. 

As regards the symptoms of this form of dermatitis, there 
is, first, a period of incubation, varying from a few hours to 
several days. In children fretfulness and slight fever may 
precede the outbreak of the eruption. The first local symptoms 
are burning, heat, and itching, usually observed on the face and 
hands, as these are the most exposed parts. The surface becomes 
reddened, with occasional livid spots, and the cellular tissue in 
the vicinity becomes cedematous. About this time the char- 
acteristic vesicles begin to appear, usually first of all between the 
fingers. The next locality involved, in males especially, is 
usually the genitals. From here the eruption may spread to 
other parts of the body. 

* For detailed information consult the monograph on Dermatitis Venenata by 
Dr. James C. White, Boston, 1887, and "Dermatitis Venenata," a supplemental 
list by the same author, Jour. Cutan. Dis., 1903, p. 441. Also Morrow's work 
on Drug Eruptions, New York, 1887. 



196 DISEASES OF THE SKIN. 

When the eruption is at its height, the surfaces involved are 
of a lurid red color, more or less cedematous, occupied by patches 
of papules and vesicles, the latter often confluent, with fre- 
quent excoriations exuding a clear yellow fluid, which gums 
on linen, and dries into a soft crust. The eyes are often closed 
from swelling of the eyelids, while the nose, lips, and ears are 
swelled, and drip with serum. The genitals are often enormously 
tumefied, and in the most aggravated cases there may be such 
excessive general oedema that the patient may be rendered actually 
helpless. In the more marked cases there is sometimes a slight 
febrile reaction, with coated tongue and constipated bowels. 
General symptoms are absent, however, in mild cases. The 
subjective sensations are usually itching and burning in the 
affected parts. In severer cases this may be intensified to a 
burning, stinging heat, and the torture may be so great as to 
deprive the patient of sleep and require the administration of 
narcotics. The eruption remains at its height for several days, 
but by the end of a week the acute symptoms have usually sub- 
sided, though a few stray lesions sometimes continue to appear. 

The diagnosis of rhus poisoning is usually made without 
difficulty, because a history of exposure to the poison vine or 
oak may almost always be obtained. In addition, the localities 
attacked are characteristic. The vesicles are usually first found 
between the fingers, where the skin is thin, then on the dorsal 
surface of the fingers and hands, and last on the thickened skin 
of the palms. The eruption is more scattered than that of 
eczema, with which affection it is most liable to be confounded, 
and the vesicles are usually developed as such, springing often 
directly from the skin without going through the preliminary 
stage of papules, as is usually observed in eczema. 

Dermatitis venenata is not, strictly speaking, contagious. 
In recent cases the poison can be conveyed from one person 
to another, or from one part to another, by simple contact of 
the surface. Thus, the penis may be handled, in micturition, 
immediately after handling the poison vine, and thus this locality 
is very apt to be attacked. 



DERMATITIS VENENATA. 1 97 

Eczema is very apt to occur as an immediate sequel to dermat- 
itis venenata, but the latter disease does not predispose to erup- 
tions of any kind as a remote result of its influence upon the system. 

White thinks that there is no evidence of a continuance or re- 
newal of the operation of the poison after its primary impression 
on the skin has exhausted itself, and therefore the accounts which 
we have of yearly recurring attacks of dermatitis venenata indicate 
renewed exposure, and not spontaneous periodical exacerbation 
of poisonous influence. 

A multitude of remedies have been, and constantly continue 
to be, suggested for the relief of rhus poisoning, some of which 
are effectual, while others have appeared to prove successful 
merely because the affection, running a spontaneous course 
toward recovery, has gotten well while they have been in use. 

In my experience the use of black wash, in the form of cloths 
kept wet with the wash and in constant contact with the skin, 
is one of the most useful remedies. White recommends the 
following : 

1$. Pulv. zinci ox., 3iv ( 16.) 

Acid, carbolic, 5j ( 4-) 

Aquae calcis, Oj. (512.) M. 

This, after being shaken, is sopped over the affected parts 
freely and repeatedly through the day and by night as well, so 
often as the patient is waked by the intense itching and burning 
which characterize the inflammation in its early stages. It 
may be applied over the whole surface of the body and for any 
length of time -with safety, and is generally well borne at any 
stage of the disease. 

Decoction of white oak bark is also useful. 

The following, recommended by Hardaway, of St. Louis, 
has done good service: 

ly. Zinci sulphat., 5ss ( 2.) 

Aquae, Oj. (512.) M. 

Sig. — Apply on cloths every hour through the day, and several times 
during the night. 



190 DISEASES OF THE SKIN. 

A remedy which is often used with great satisfaction is the fluid 
extract of grindelia robusta : 

1$. Ext. grindeliae robustae, fluid., foij-iv (816.) 

Aquse, Oj. (512.) M. 

This is to be applied to the affected parts on cloths, which are to 
be thoroughly wet with the solution and then allowed to dry almost 
completely upon the skin, removing them when nearly dry and 
renewing the application, but not keeping the cloths constantly 
sopping wet, as with other sedative and astringent lotions. 

Astringent powders may also, at times, find appropriate place, 
as on the face, when the patient is obliged to go about, and can- 
not keep wet cloths, etc., applied. The following may be men- 
tioned : 

I£. Pulvis zinci carb. praecip., 

Amyli oryzae, aa oj. (32.) M. 

Or this: 

1^. Magnesii carbonatis levis, 

Pulveris lycopodii, aa oss. (16.) M. 

At times none of these applications seems effectual, when the 
employment of some simple domestic remedy, as a solution of 
washing soda in water, gives relief. I am inclined to think 
that failure more frequently results from inadequate or improper 
application of remedies than of the want of virtue in the latter. 

Most patients presenting themselves with rhus poisoning are 
children, on whom it is difficult to apply any remedy effectually. 
The parts affected are often difficult to cover, and constant 
movements cause the best placed bandages to be quickly mis- 
placed. If it were possible to place some fixed adhesive dressing, 
this would be of advantage, but where there is much secretion 
such applications will not remain long in contact with the skin. 
A solution of tar, or oil of cade in collodion, or gutta percha one 
drachm to the ounce, may be used on parts where the itching 
is severe, and where the skin has not yet been broken. The 
advantage of this is that small scattered patches can be covered 
without the necessity of extensive dressings. 



DERMATITIS VENENATA. 1 99 

White recommends a solution of gelatine in glycerine and 
water : 

1$. Gelatin, oiv ( 16.) 

Glycerin, . . f 5 j ( 32.) 

Aquae destillat., ad f§iv. (128.) M. 

This may be used when the skin is broken, and, by the addi- 
tion of a drachm (4.) of boric acid, may be made antiseptic at 
the same time. 

When washes have been used in the daytime, they may be 
replaced by ointments at night. These should usually have 
vaseline as a base. 

The following may be suggested: 

1$. Acid, tannic, gr. xv ( i.) 

Petrolat., oj. (32.) M. 

Or salicylic acid may be employed in the same proportion as 
the tannic acid. 

When there is much itching carbolic acid may be used in the 
ointment : 

T$. Acid, carbolic, gr. x-xx ( .6-1.2) 

Hydrarg. chlor. mite, gr. x ( .6) 

Pulv. amyli, 5j ( 4- ) 

Petrolat., oj. (32. ) M. 

The calomel should be used with caution, or omitted when 
the surface to be covered is considerable. 

Where constipation exists, it is well to give a purgative at the 
beginning of the treatment. No other internal treatment is 
required. 

The prognosis of this form of dermatitis is, of course, favorable, 
although the occurrence of successive crops of eruption may 
delay the cure for some weeks. 

(Various other plants are mentioned by Dr. J. C. White, in his 
very complete monograph on "Dermatitis Venenata," as known 
or believed to exercise an irritant and poisonous action on the 
skin. Among these, which are very numerous, the best known 
are the following: Cashew nut, Indian turnip, skunk cabbage, 



200 DISEASES OF THE SKIN. 

the upas of Java, cultivated at times in our gardens ; bitter orange, 
catalpa, arnica montana (not the American arnicas), flea-bane, 
burdock, euphorbia, manchineel of Florida, mucuna pruriens or 
cowhage, flax?, bayberry (employed in making cheap "Bay 
rum"), poke, smartweed, wood anemone, clematis, larkspur, 
buttercup, ipecac, cinchona and quinine, Balm oj Gilead, mezereon, 
thapsia, nettle, hyacynth bulbs, etc. 

Of inorganic substances which may give rise to dermatitis 
are paraffin, petroleum, common or sea salt, bichromate of potas- 
sium and aniline dyes. In addition, a number of drugs may 
produce the same condition. Some, if not all, of these will be 
found mentioned under Dermatitis medicamentosa. Of the 
animal kingdom, mention may be made of the lower forms of 
marine life — hydroa, medusa; , polyps, etc. — of which the best 
known are the Portuguese Man-of-war, the jelly fishes generally 
and sea urchins. The commoner animal parasites will be found 
mentioned under their various names, or that of the diseases they 
produce, as bed-bug, scabies, pediculosis, etc. Reference may be 
made to the monographs of White, Piffard, and Morrow for 
fuller details. 

(Advantage is sometimes taken by malingerers and hysterical 
persons of the known action of the agents mentioned above to 
produce artificial eruptions.) 

X-RAY DERMATITIS. 

The Rontgen ray, at present used extensively in the treat- 
ment of various diseases of the skin, may itself, if incautiously 
used, produce a dermatitis at times extremely intractable to 
treatment. 

The first signs of cutaneous disturbance sometimes do not 
present themselves for several days or longer after exposure. 
The milder forms occur as a peculiar reddish flush or erythema 
resembling sunburn and which, in the course of several days 
to a few weeks, gradually disappears. In other cases, freckles, 
telangiectases, growth of downy hairs in smooth places, or 
temporary falling of the hair where this naturally grows may 



X-RAY DERMATITIS. 201 

occur. Sometimes the erythema is rapidly succeeded by a super- 
ficial, ill-defined vesiculation and with or without a trifling swell- 
ing or pufhness; such cases often give rise to a good deal of pain. 
Sometimes exfoliation follows the erythema. In those whose 
hands are constantly exposed to the ray, as with physicians making 
constant use of it professionally, a persistent redness with scali- 
ness ensues. Sometimes this may become permanent or lead to 
atrophic changes. In a few cases keratoses have resulted, fol- 
lowed by carcinoma. 

Such cases are rare and may for the most part be referred back 
to the early employment of the X-ray by inexperienced operators. 
However, the possibility of atrophic and other changes occurring 
must be kept in mind and due caution should be employed in 
the treatment of benign skin diseases. In a very few instances 
the destructive effect of the ray has gone so far as to give rise to 
sloughing with the production of excessively painful ulcers of a 
more or less permanent character. 

The etiology and pathology of X-ray dermatitis are at present 
in doubt. Most observers consider the changes as trophoneu- 
rotic in character. Macleod* concludes that the X-rays in small 
doses have a stimulating effect on the elements of the healthy 
skin. Large doses are capable of devitalizing the tissue ele- 
ments, interfering with the process of reproduction and causing 
their degeneration. The more highly differentiated structures, 
such as the hair follicles, glands, nails and blood-vessels, are 
more readily and severely affected by the rays than the less 
differentiated epidermal cells or the fibrous stroma of the corium. 
Pathologically altered cells, whether of epiblastic or mesoblastic 
origin, are far less resistant to the rays than healthy cells, and 
are devitalized by small doses of the rays. This destructive ac- 
tion on diseased elements may be taking place while the healthy 
elements in the neighborhood, instead of having their vital- 
ity inhibited, may be stimulated to a process of repair. The 
action of the rays is cumulative and when the cellular degenera- 
tion reaches a certain degree the toxic products of the breaking- 

* Brit. Jour. Derm., 1903, p. 365, quoted by Stelwagon. 



202 DISEASES OF THE SKIN. 

down cells are capable of setting up an inflammatory reaction, 
which is a secondary phenomenon. This inflammatory reaction 
is peculiar in that it occurs in a tissue, the vitality of whose various 
elements has already been impaired by the action of the rays, 
and in that it is associated with greater destructive changes than 
those produced by the actinic rays and is apt to lead to ulcera- 
tion and necrosis, and is liable to be followed by an imperfect 
process of repair. 

The treatment of X-ray burns is largely preventive. The 
dangers of too long and too frequent exposure, too close proximity 
and a high current intensity are so far as possible to be avoided. 
In the treatment of limited areas the interposition of sheets of 
lead with windows of requisite size to permit the exact area de- 
sired only to be exposed will be found useful. In operating 
upon the face I use a wire mask covered with a number of 
sheets of tin-foil with an opening the size of the lesion to be 
operated upon. 

The milder forms of X-ray dermatitis require the same soothing 
applications as are employed in the treatment of acute eczema 
and simple dermatitis. When stubborn ulceration takes place 
curettage with subsequent skin-grafting appears to be the only 
recourse. 

The prognosis of the milder forms of X-ray dermatitis and even 
where slight ulceration has taken place is favorable eventually. 
In the more severe ulcerations the prospect is unfavorable. 
Fortunately such cases are extremely rare and when the manage- 
ment of the ray is in skilled and judicious hands should scarcely 
ever occur. 

DERMATITIS FACTITIA. 

Feigned diseases of the skin include those various forms of dis- 
ease which are artificially produced with the intention to deceive. 
Such affections are usually seen in beggars, criminals, soldiers, 
sailors, and others who may have an object in deceit, or they may 
be self-produced in hysterical or insane persons. In the latter 
case the occurrence of hysterical neuroses must be taken into 



DERMATITIS FACTITIA. 203 

account for it is often difficult to distinguish a pure neurosis 
from a partly artificial or a wholly artificial eruption. 

Among the skin affections which have been imitated are javus, 
alopecia areata, tinea tonsurans, scabies, bromidrosis, hcematidrosis, 
chromidrosis, urticaria, ulcers, erysipelas, various forms of derm- 
atitis, etc.* Of these the various forms of dermatitis are the 
most interesting because they occur among hysterical persons 
and often without any explicable motive. Indeed, cases are on 
record where a true hysterical dermatoneurosis has occurred at 
one time while later a factitious imitative eruption of the same 
character has been observed.! 

Mechanical irritation may be employed, with the result of 
giving rise to eruptions resembling one of the usual forms of 
dermatitis. Sangster described the case of a young girl, where 
the diagnosis was made first as "abortive herpes," and later as 
"neurotic excoriation," where painful erythematous patches 
were succeeded by exudation on the surface of serum and sero- 
pus, each patch terminating in desquamation, and running its 
course in ten to fourteen days. There was no vesiculation or 
loss of substance. The longest interval during which the patient 
had been free from the lesions was three months. The case 
came under observation at intervals for three years, but finally 
Sangster was able to satisfy himself that the lesions were pro- 
duced purposely by forcibly tearing with the nails. 

Stelwagon has described the case of a girl of nineteen, pale, 
nervous, and suffering from hysterical aphonia, who applied for 
relief for an eruption which had persisted almost uninterruptedly 
for three months, and which consisted in groups of two or more 
parallel, elongated, crusted lesions, situated on the flexor and 
extensor surfaces of the forearms and on the tibial surfaces of 
the legs, with eczemaform patches in the flexure of one elbow 
and on one instep. The crusts resembled those of impetigo 
contagiosa. The patient, who had been for some time unsuccess- 
fully treated, was finally suspected of simulation, and on being 

*See Laugier, Die. de Med. et de Chir. Practiques, Art. Maladies Simulees. 
|See the case of Louise Lateau under Hcematidrosis. 



204 DISEASES OF THE SKIN. 

closely questioned, confessed having produced the lesions by 
constant rubbing with the finger ends. The sensation thus 
given was an agreeable one, and it was this, she asserted, and 
not the desire to gain sympathy, which was her object. 

Bazin reported a case in which a young girl succeeded in 
producing an eruption of bullae by introducing cantharides 
powder under the epidermis. Pierrepont (Sajous' Annual, vol. 
iv, 1889, p. 62) gives a similar case caused by fly blisters. A 
case was reported by the late Dr. Fagge, of London, in which a 
young girl caused an eruption of bullae resembling those of 
pemphigus by the application of nitric acid to the skin. 

Feigned diseases of the skin are often very difficult of diagnosis. 
On the one hand, care must be taken not to mistake professional 
eruptions, as bakers', bricklayers', sugar-boilers', bartenders' 
dermatitis, or the eruptions produced by the ingestion of drugs 
(see Dermatitis medicamentosa) or of certain edibles, for facti- 
tious eruptions; and, on the other hand, it must be remembered 
that various skin diseases may be closely simulated by artificial 
means, and that such deception may be kept up for months. 
In the case of soldiers and prisoners, where fraud may be sus- 
pected, such measures as bandaging, surveillance, etc., may be 
practiced; but among hysterical females of the better classes the 
difficulties of diagnosis are heightened by the fact that factitious 
eruptions may be caused by a sort of automatic mental impulse, 
and without any perceptible object. 

Two points must be remembered in such cases. First, the 
disease is almost always anomalous in the time, place, or manner 
of its appearance and in the course it runs. Second, it almost 
always shows some sign of having been artificially produced, and 
is almost invariably in a position easily and conveniently access- 
ible to manipulation. Thus the face, forearms, chest, and mam- 
mary region, and after these the lower limbs, are most apt to be 
the seat of the eruption. If, in addition, any motive for malin- 
gering, or for exciting interest and sympathy, can suggest itself, 
the case should be carefully looked into from this point of 
view. The lesions and their neighborhood should be examined, 



DERMATITIS MEDICAMENTOSA. 205 

with a view to detecting any trace of the use of mechanical 
irritants, or of such domestic articles as are apt to be used; mus- 
tard, vinegar, cantharides, nitric acid, etc., have all been employed. 
The examination should always be so made as to avoid suspicion 
of its object, and if the physician comes to a positive conclu- 
sion that the eruption, in any given case, has been artificially 
produced, let him not think of proclaiming his conclusion, 
which will probably only lead to the suspicion, on the part of 
friends and relatives, that he does not know his business. Better 
to treat such cases with placebos, and have them recover spon- 
taneously, without forcing the patient to admit a deception, or 
pitting one's reputation for sagacity against the patient's veracity. 
Of course, I have chiefly in mind the case of hysterical women 
feigning skin diseases. 

DERMATITIS MEDICAMENTOSA. 

Drug eruptions are those produced by the ingestion of sub- 
stances ordinarily used as medicines. These must be taken 
up into the system to produce the effects here understood. The 
direct irritative effects caused by the application of drugs to the 
surface are described under the head of Dermatitis venenata. 

Some drugs, as iodine and its salts, will produce eruptions 
in almost any individual if taken in considerable quantity or 
for a sufficient length of time; others, as quinine, only produce 
an effect in persons having a peculiar idiosyncrasy toward the 
drug. The following drugs have been known to produce erup- 
tions upon the skin as a result of their ingestion: Arsenic, 
antipyrine, anacardium, anitmony tartrate, belladonna and atro- 
pia, bitter almonds, bromine, borax, benzoic acid, boric acid, can- 
nabis indica, chloral, copaiba, cubebs, digitalis, duboisia, hyo- 
scyamus, iodine, iodoform, mercury, opium, pilocarpine, phos- 
phoric acid, quinine, salicylic acid, santonine, tar and its deriv- 
atives and congeners, turpentine, carbolic acid, creasote, rosin, and 
petroleum* 

*A large number of other drugs ai*e enumerated by writers on the subject. 
See Morrow on Drug Eruptions, also Hyde and Montgomery, and Stelwagon. 



206 DISEASES OF THE SKIN. 

The eruptions produced by these drugs are generally limited 
to a few pretty well-defined groups, and bear a family resem- 
blance to one another. Erythematous, scarlatiniform, and 
urticarial rashes are usually met with. Less frequently, pustu- 
lar, bullar, purpuric, or nodular eruptions are encountered. 
There is nothing about the appearance of these eruptions which 
is so characteristic that the drug causing it can be pointed out 
in any given case. We are able, however, in most instances, 
to designate an eruption as due to the effect of some drug, because, 
while resembling closely some other eruption in its lesions, the 
drug eruption is always different in some well-defined symptom. 
It may be excessively profuse, or it may be accompanied or 
unaccompanied by fever, contrary to the usual rule, or the 
lesions may occur in some unusual place and run a peculiar 
course. 

The eruptions due to iodine and bromine differ so much from 
the other drug eruptions that they are best considered at length. 
There is an erythematous eruption due to bromine, which may 
occur in any part of the body, but is usually confined to the 
lower extremities; it is diffuse, and at times painful. A maculo- 
papular eruption has been described as occurring on the face 
and neck, the skin having a congested violaceous hue, with a 
copious eruption of maculo-papules and pustules, with enlarge- 
ment of the sebaceous ducts and the formation of sebaceous 
crusts. The skin is flushed, but does not itch. As there is 
some fever and constitutional disturbance, this eruption may be 
mistaken for the erythematous syphiloderm, but the sebaceous 
character of the lesions is characteristic. 

Wigglesworth has described a bullous eruption due to bromine, 
and characterized by lesions which were somewhat acuminated 
and varied in size from that of a split pea to the end of the finger. 
In some instances the bullae ruptured, leaving sometimes a 
simple fringe of torn epidermis, and sometimes an ulcerated 
surface. Some of the bullae appeared to contain blood. 

The pustular eruptions due to bromine are better known 
than any of the other varieties. In their simplest form, resem- 



DERMATITIS MEDICAMENTOSA. 207 

bling acne, they occur sooner or later in almost all persons sub- 
jected to a course of the bromides. Occasionally a furunculoid 
or anthracoid eruption is observed. Here the smaller lesions are 
pea-sized, prominent, convex, vesico-pustules, seated on a hard, 
slightly elevated base, and surrounded by a vividly red areola. 
The larger lesions are flattened elevations, covered by a moist, 
flaccid cuticle, or thick, light brown crust, and surrounded by a 
dark red areola. The crust or cuticle being removed, the sur- 
face beneath presents numerous pin-head-sized, yellowish-red 
protuberances. The secretion is found to be chiefly sebaceous 
in character. These confluent lesions may be from one-fourth 
of an inch to several inches in diameter. The peculiarity which 
chiefly distinguishes this form of bromide eruption from acne 
is that it may occur in any locality, often being found where 
acne never occurs, and neglecting entirely the favorite localities 
of that disease. 

A bromine eruption is occasionally met with which resembles 
the eruption of erythema nodosum. 

In the diagnosis of bromine eruptions the dusky rose or viola- 
ceous color of the lesions must be taken into account, and also 
the distribution of the lesions, the fcetor of the breath, and the 
presence of bromine in the urine must be considered. Of course, 
the history is of importance. 

With regard to the amount of the drug necessary to produce 
these skin eruptions, it can only be said that it varies greatly. 
While usually it is requisite that bromine or its compounds should 
be taken in considerable doses, and for some length of time, 
yet cases are on record in which very small doses have quickly 
brought out a characteristic eruption. 

Like the eruptions due to bromine, those due to iodine have, 
some of them, at least, been familiar for a long time. The 
eruptions from iodine may be erythematous, papular, vesicular, 
bulbar, pustular, or hemorrhagic. The erythematous form shows 
itself in large disseminated patches in various parts of the body, 
sometimes forming a sort of iodic roseola. The forearms are 
usually attacked. If the use of the iodide is persisted in, the 



208 DISEASES OF THE SKIN. 

eruption may pass on to the papular form. The papular erup- 
tion is characterized by heat of the skin, with reddish patches, 
on which are situated numerous large papules elevated very 
slightly above the surrounding skin, sometimes disseminated 
over the surface generally. This form of eruption is not unlike 
urticaria, but has a brighter and less circumscribed coloration. 
It is rare. Vesicular eruptions resembling eczema are said to 
have been caused by the ingestion of iodine or its compounds, 
and several observers have reported a peculiar bullous eruption 
situated usually upon the head, neck, or upon the upper extrem- 
ities; less frequently upon the lower extremities and trunk. The 
lesions begin as pin-point-sized vesicles, or as shot-like papules, 
at the apices of which vesiculation subsequently occurs. The 
lesions are pale, yellowish-white and glistening. If the iodine 
be persisted in, and especially if given in large doses, the bullae 
change to red and purple, and become filled with sero-pus and 
even ichor. In a few instances blood has been found in the 
bullae at an early stage. 

The pustular eruption due to the ingestion of iodine or its 
compounds is in almost every respect analogous to that pro- 
duced by the bromides, only that the confluent form is ex- 
tremely rare. It is peculiar in its subjective symptoms, itching 
at first, and later giving rise to severe throbbing pain. This 
symptom, together with the violaceous color of the lesions, and 
their cheesy, non-purulent contents, serves to distinguish the 
iodine eruption from syphilis or any other disease with which 
it is liable to be confounded. 

A purpuric eruption due to the ingestion of iodine or its com- 
pounds is now and then met with. It may be brought on even by 
minute doses of the drug, the case of an infant having been re- 
ported where a fatal result was caused by a single dose of two 
and a half grains. Usually, however, the eruption is not severe, 
and is found upon the legs. Now and then other hemorrhages 
may be caused simultaneously. It is usually produced at an early 
date from the first exhibition of the drug, but its appearance is 
occasionally delayed until the drug has been administered for 



VARICELLA. 200, 

some time. The purpuric eruption ceases when the iodine is 
stopped, but may be reproduced by even minute doses.* 

Both the iodine and bromine eruptions may often be pre- 
vented by the simultaneous administration of arsenic. As 
much as ten minims of Fowler's solution may be given in each 
dose when this is borne by the patient. Paget recommends the 
administration of aromatic spirits of ammonia with the same 
view. 

The other drug eruptions, aside from those due to bromine and 
iodine, may be classed together, on the ground that they are almost 
always of an exanthematous character, resembling scarlatina, 
measles, roseola, urticaria, etc., and that idiosyncrasy bears a 
much more important part in their production than in the case 
of the drug eruptions described above. 

As regards the manner of the production of drug eruptions, 
this question has not as yet been settled. Three theories have 
been advanced: (i) That of skin elimination, the drug acting as 
an irritant as it passes through the cutaneous tissues or glands. 
(2) Increased skin elimination due to defective condition of the 
ordinary eliminative organs, more particularly the kidneys. (3) 
The neurotic theory, the action being either purely reflex, anal- 
ogous to urticaria ab ingestis, or due to the influence of the drug 
upon the vaso-motor centers or on the peripheral nerves. 

VARICELLA.f 

Varicella, or chicken-pox, is a contagious, febrile, systemic 
affection of benign type, occurring chiefly in children, and 
characterized by an eruption of discrete, scattered, superficially 
seated, thin-walled, usually small-pin-head to pea-sized vesicles. 

The disease has an incubative period of ten to fourteen days, 

* Among recent contributions on the subject, see Lorta Wright Myers, " A Rare 
Bromide Eruption." Jour. Cutan. Dis., 1904. p. 231; Pollitzer "Iodoform Erup- 
tion from Mesotan." lb., '03, p. 466; also D. W. Montgomery, "A Tuberous 
Iodid of Potassium Eruption Simulating Histologically an Epithelioma. ''lb., 
1904, p. 65. 

t The other exanthemata, scarlatina, rubeola, rotheln and variola are so ex- 
tensively described in the text-books of general medicine that it has not been 
thought advisable to include them here. 

14 



2IO DISEASES OF THE SKIN. 

after which occur malaise, chilliness and languor. The patients, 
usually children, then suffer from a fever of 99°-ioo° F., lasting 
from a few hours to two or three days, after which defervescence 
is commonly complete. 

With the onset of the fever,, or in many cases, without any 
fever, the rash appears at first upon the head and trunk and 
later in other localities in successive crops, assuming at first 
the form of rosy macules or slightly elevated lesions, lacking the 
characteristic shot-like feeling of the variolous papule. The 
vesicle rapidly forms on this macular base, pin-head to pea- 
sized, rounded or oval, rising well from the surface with 
limpid contents. When fully developed, the underlying papule 
or macule usually fades, leaving the clear vesicle standing 
directly out from the skin without any areola. The eruption 
varies greatly in extent in different cases. It may be quite 
abundant or, in some cases, scanty, and even occasionally one 
or two lesions are all which are to be discerned. 

The individual lesions reach full development in several hours 
to one or two days, by which time desiccation has already set 
in, drying to thin film-like crusts. The lesions leave no scar 
as a general thing, but sometimes, whether as a result of purulent 
infection or otherwise, deeper action takes place and a small 
pit results. The process is, as a rule, ended and the crusts 
fallen off in from seven to twelve days after the inception of the 
disease. 

Varicella is contagious and by some believed also to be inocul- 
able. A second attack in the same individual is extremely rare. 
The attack, it need hardly be said, does not protect against small- 
pox. It is a disease of children, most cases occurring between 
the ages of one and five, rarely it has been observed in adults. 

The diagnosis of varicella is to be made from the lightness or 
absence of systemic disturbance, the scattered distribution of 
the eruption, usually upon the trunk and also upon the scalp, 
the superficial nature of the lesion, its thin, easily ruptured wall 
and the irregular crop-like appearance of the eruption. The 
disease is to be carefully differentiated from small-pox. Very 



VACCINAL ERUPTIONS. 



211 



unfortunate results occasionally result from mistaking one af- 
fection for the other.* 

The prognosis of varicella is favorable in all cases. Treat- 
ment should be largely expectant. 



VACCINAL ERUPTIONS, t 

The vaccinal eruptions may be divided into two classes: (i) 
Eruptions due to pure vaccine inoculation, and (2) eruptions 
due to mixed inoculations. The following table shows the 
various eruptions displayed. (Frank.) 



f Local 



(1) Due to vaccine virus \ 



I Systemic 



(2) Due to mixed inocula- 
tion introduced at time 
of vaccination or subse- 
quently. 



I Local 



^ Systemic 



f Local erythema 
J Dermatitis 
I Local vaccinia 
I Adenitis 

f More or less generalized ery- 
thema (erythema vaccinium, 
roseola vaccinia) 
i Urticaria 

Erythema multiforme 
Vaccinia (generalized vaccinia) 
Purpura. 

I Impetigo contagiosa 
Furunculosis 



Cellulitis 
Erysipelas 
Gangrene 
Tuberculosis cutis 

Gangrene 

Pyaemia 

Syphilis 

Leprosy 

Tuberculosis 



*See Morrow "On the Diagnosis of Small-pox," Jour. Cutan. Dis., 1886, p. 
72, and for the sad result of mistaken diagnosis, Dyer on the "Differential Diag- 
nosis of Varicella and Variola," New Orleans Med. and Surg. Jour., Jan., 1896. 

fSee Malcom Morris, B. Med. Jour., Nov. 29, 1890; Frank, Jour. Cutan. Dis., 
1895, P- J 42; Dyer, New Orleans M. and S. Jour., Feb., 1896; Stelwagon, /. Am. 
M. A., Nov. 22, 1902, and Corlett, Jour. Cutan. Dis., 1904, p. 495. 



212 DISEASES OF THE SKIN. 



(3) Sequelae of vaccination 



Eczema 

Urticaria 

Pemphigus 

I Psoriasis 

I Furunculosis. 



The vaccinal eruption most frequently seen is the erythema, 
which in ordinary cases surrounds the point of vaccination 
like an areola, sometimes spreading from this point and at other 
times showing itself in scattered patches over various parts of 
the surface. Next to this in frequency are the urticarial and 
erythema-multiforme-iike eruptions. A regional, vaccinia-like 
eruption sometimes met with may be impetigo contagiosa. 
Adenitis is often present. 

There appear to be two periods for the occurrence of vaccinal 
eruptions, the first three days or after the ninth day. Eczema 
and psoriasis sometimes start from vaccination in persons prone 
to these diseases. In other instances vaccination seems to 
have a beneficial effect on previously existing eruptions. 

Serious diseases as syphilis, leprosy, tuberculosis, have been 
inoculated in vaccination, but such cases are extremely rare 
and in the present state of our knowledge need never occur. 
Ordinary vaccinal eruptions cannot always be prevented and 
the physician should never be blamed for such untoward occur- 
rences if ordinary precautions have been taken. Strict antiseptic 
and protective treatment should be carried out immediately 
after the vesicles have developed and the cases should be seen 
from time to time by the vaccinator until the wounds have 
healed. 



PURPURA. 213 



CLASS III. HEMORRHAGES, 
PURPURA. 

Purpura is an affection of the skin, characterized by the 
appearance of hemorrhagic spots of various sizes, and accom- 
panied or not by similar hemorrhages in the mucous membranes 
and viscera. It may be idiopathic or symptomatic. The idio- 
pathic form commonly presents itself in two varieties, P. simplex 
and P. hemorrhagica. Purpura simplex is characterized by 
the appearance, in successive crops, of numerous petechial 
spots in the skin and visible mucous surfaces. These are usually 
attended with little or no constitutional disturbance, although 
malaise, loss of appetite, etc., may precede the outbreak of 
the eruption by some days. The spots come out suddenly; 
often in the night, and the patient finds his skin, usually the legs 
and about the knees, strewn with sharply-defined, pin-head to 
pea-sized hemorrhagic lesions. The color of the eruption, at 
first bright red, soon becomes purplish, and the lesions may be 
single and scattered, or here and there mingled in irregular 
patches. The only subjective symptom observed is slight 
itching on the appearance of the lesions; often even this is absent. 
Occasionally wheals, like those of urticaria, occur with the 
hemorrhages, and then there may be much itching. Blebs have 
been noticed in this form of purpura. 

Purpura simplex is more apt to be observed in the old than 
in the young. An attack may last from a fortnight to several 
months, the cutaneous lesions coming out in crops. The causes 
are often obscure; it occurs in the well-nourished as well as the 
debilitated. Malarial influences also have an effect in causing 
the disease. 

The lesions of purpura simplex are so peculiar, being small 
hemorrhages under the skin which do not disappear on pressure, 
that there is usually no difficulty in making a diagnosis. The 



214 DISEASES OF THE SKIN. 

lesions may, however, be confounded with flea-bites. The 
puncture made by the insect in the center of each hemorrhagic 
point will, however, settle the diagnosis. 

There is one form of purpura simplex which is known as 
purpura rheumatica, where the prodromal symptoms are more 
severe, and where severe rheumatic pains are felt, especially 
in the joints of the lower limbs. When the eruption comes out 
the rheumatic symptoms abate; relapses here are common; 
the disease may last for months, and sometimes takes on the 
appearance of erythema multiforme. Under the name peliosis 
rheumatica or Schonlein's disease, a rare affection beginning, 
sometimes with severe sore throat and displaying symptoms of 
purpura, rheumatism and erythema conjoined, has been described. 

Henoch's purpura, chiefly observed among children, seems in 
some cases to be a combination of purpura and angioneurotic 
oedema. It is apt to be accompanied by gastro-intestinal crises — 
pain, vomiting and diarrhoea, joint pains or swelling, and hemor- 
rhages in the mucous membranes. Recurrences are common. 
Acute hemorrhagic nephritis may occur in severe cases (Osier). 

The second variety of idiopathic purpura, P. hemorrhagica, 
also known as morbus maculosus Werlhofii, is a much more severe 
disease. It begins by marked prodromal symptoms, as debility, 
loss of appetite, languor, headache, and a feeling of general dis- 
tress. The spots of eruption appear suddenly, first upon the 
limbs, and then spreading to other parts of the body, occurring 
usually in great numbers and often coalescing to form hand-sized 
patches. Hemorrhages from the mouth, gums, nose, stomach, 
bowels, and bladder, and even into the brain, may occur simul- 
taneously and the disease may have a fatal termination. The 
disease may occur at all ages, and among the strong and well- 
nourished, as well as among the weak and ill-fed. 

The symptomatic forms of purpura are those in which the 
hemorrhage into the skin is a comparatively insignificant 
symptom of a more important disease. The specific fevers, 
various forms of anaemia, leucocythemia and scurvy form one 
group of these. Another is formed of cases where the extrav- 



PURPURA. 215 

asation of blood into the skin is caused by the ingestion of 
drugs. A third group includes cases occurring from mechanical 
causes, as feeble circulation, varicose veins, thrombosis, etc. 
A fourth group includes all those cases in which the nervous 
system is primarily at fault, as tabetic purpura, purpura in 
connection with diseases of the central nervous system and 
neuralgia, etc. 

The etiology of purpura is still somewhat obscure. No one 
cause can be set down as essential in all cases. In addition to 
the ingestion of certain medicines, notably iodine and its com- 
pounds, salicylic acid and chloral, such influences as malaria, 
scorbutus, anaemia, etc., may give rise to the eruption.* Levy thinks 
the purpura in these cases is microbic in origin — one variety may 
be toxic and one septicaemic. In the first variety, toxins are 
formed by the microbes confined to certain organs (for example, 
the intestinal tract after eating spoiled meat) which act on the 
vaso-motor nerves through tbe blood by which a dilatation and 
finally a rupture of the capillaries of the skin are produced and 
followed by the characteristic appearance of macules. In the 
septic form the microbes are directly carried beneath the skin 
into the blood current and become the cause of microbic emboli. 
The effect may be increased if the microbes situated under the 
skin should, by chance, produce toxins which might act on the 
vaso-motor nerves. Some purpuras of toxic origin may arise 
from intestinal auto-intoxication. 

In grave types of purpura there is usually great diminution 
in the red blood corpuscles. In a case reported by Cureton, three 
days before death these numbered 1,680,000, rapidly going down 
to 310,000. 

Anatomically the effusion has its seat in the corium, especially 
the papillae and sometimes in the subcutaneous tissue as well; 
the involved blood-vessels are usually dilated and filled with 
red blood corpuscles. 

The diagnosis of purpura presents, as a rule, no difficulty. Few 

*See Shattuck "Lymphatic leukemia, with Purpura" (case), Jour. Cut. Dis., 
1904, p. 118; also Engman " Malaria Purpura," lb., 1903, p. 489. 



2l6 DISEASES OF THE SKIN. 

or no other diseases excepting scurvy are attended by effusions of 
blood under the skin. In scurvy the disease occurs in persons 
deprived of vegetable food and fruits and is generally preceded 
or accompanied by softening and sponginess of the gums, bleed- 
ing of the latter and loosening of the teeth* The hemorrhagic 
lesions are also usually limited to the legs and ankles with a 
tendency to swelling of the parts. 

Flea-bites have been mistaken for purpura but the evidence 
of a central puncture and their scanty number should distinguish 
these lesions from those of purpura. 

The prognosis of purpura must always be expressed with a 
certain caution. Cases beginning mildly sometimes later become 
quite serious. Most mild cases, however, terminate favorably 
after an indefinite time, varying from a few weeks to several 
months. In hemorrhagic purpura the prognosis is grave. 

In the treatment of purpura, attention must first be paid to the 
removal of the cause, if this can be ascertained. Nutritious 
diet, and above all, if the hemorrhage be extensive, perfect 
rest in the horizontal position, are important. In purpura 
simplex, ergot, iron and quinine, the mineral acids, together 
with frictions and cold baths, are beneficial. Purpura hemor- 
rhagica calls for prompt and decided treatment. In addition 
to perfect rest and diet in ordinary cases, tincture of the chloride 
of iron in doses of twenty to thirty drops, alone or with ergot 
and digitalis, may be given. Turpentine and acetate of lead, 
with opium, may be administered in some cases. Nitrate of 
silver in J grain (0.0108) doses two or three times a day has been 
used with success. Calcium chloride in 15-30 grain (1-2) doses 
three times a day has also been recommended. It should only 
be used a few days as it in time deminishes the coagulability 
of the blood. Oil of erigeron, in five or ten-drop doses, on sugar, 
every two or four hours, is highly recommended. In severe 
cases ergotine may be given hypodermically, one grain (0.065) 
every four hours. Electricity has succeeded when other remedies 
have failed. Finney recommends ergot and belladonna at first, 
and bark, ammonia, and the mineral acids later. 



PURPURA SCORBUTICA. 21 7 

PURPURA SCORBUTICA. 

Purpura scorbutica or scurvy is closely allied in its skin manifestations to 
typical purpura. Scurvy, however, is due to long-continued deprivation of 
proper food, especially fruits and vegetables, with the accompaniment of 
other bad hygienic conditions. It usually occurs among sailors but may 
also occur on land and especially among improperly or insufficiently fed 
infants. 

The symptoms are general emaciation and loss of strength, swelling of 
one or more joints, and a more or less swollen, spongy and even gangrenous 
condition of the gums. Concomitantly, dark purplish, hemorrhagic patches 
appear upon the lower portion of the legs, sometimes small hemorrhages oc- 
cur, but in any case the color is more dusky than the petechia and ecchy- 
moses of ordinary purpura. Ulceration takes place in some cases both in 
the skin and the gums. Hemorrhages from the mucous surface, fcetor of the 
mouth, exhaustion and death may supervene in severe cases. 

The treatment of purpura scorbutica consists in the removal of the patient 
from the bad hygienic conditions which have caused the disease, and placing 
him under the most favorable conditions possible. Lemon or lime-juice and 
abundance of fresh vegetables should be supplied. In some cases the usual 
tonics, iron, quinine and strychnine are required. Locally the gums and 
mouth should frequently be washed out with diluted tincture of myrrh " eau 
de Botot " or other astringent mouth washes. In some cases the limbs may 
be bandaged but local treatment is not often necessary. 

Closely connected with purpura is the hemorrhagic condition, known as 
"bloody sweat," or " haematidrosis," which consists in the appearance at the 
outlets of the excretory ducts of the sweat glands of a reddish fluid contain- 
ing blood. It is usually in small quantity and localized, and is a cutaneous 
hemorrhage, taking place about the sweat glands, and emptying itself through 
the sweat ducts. It is a very rare disease. (See Hcematidrosis.) 



2l8 DISEASES OF THE SKIN. 



CLASS IV. HYPERTROPHIES. 
LENTIGO. 

Lentigo, or freckles, are yellowish, brown or blackish pigmen- 
tary, circumscribed cutaneous macules, varying in size from a 
pin-head to that of a pea or larger, and appearing for the most 
part on exposed regions, as the face and backs of the hands. 

Exceptionally freckles may occur on the back, thighs, buttocks, 
etc. They are usually met with in the young and are more apt 
to occur in the summer months and after exposure to the sun. 
They do not give rise to any subjective symptoms. 

Occasionally lentigo is an early symptom of the exceedingly 
rare disease of the skin, xeroderma pigmentosum. In old persons 
freckles appear on the backs of the hands and to a less degree 
on the face as the precursors of senile warts. 

Freckles consist of a circumscribed amount of pigment in 
the rete mucosum — merely, in fact, a localized increase in the 
normal pigment, differing from chloasma only in the size and 
shape of the pigmentations. 

The treatment of lentigo is unsatisfactory. The pigment 
spots may be removed but if at all numerous they tend to return 
almost immediately. A lotion of bichloride of mercury of 
one to four grains to the ounce of alcohol and water will often 
cause peeling of the epidermis which will bring off the pigment 
with it. Peroxide of hydrogen will also clear off superficial 
freckles. Other preparations may be found in the larger works 
on diseases of the skin. 

CHLOASMA. 

Chloasma is a pigmentary hypertrophy of the skin, character- 
ized by the appearance of variously sized and shaped yellowish, 



CHLOASMA 219 

brownish, or blackish patches, or as more or less diffused dis- 
coloration. 

The eruption begins slowly and insidiously and may not 
attract attention until a considerable area is involved. The 
only symptom is the deposit of pigment. There is no elevation, 
the surface of the skin remains smooth, except in a few cases 
where the sebaceous glands seem to be involved, and there are 
no subjective symptoms. The face is the part most frequently 
attacked, although it may be found on the trunk or limbs. 

Idiopathic chloasma includes all those cases in which the pig- 
mentary increase is due to external agents, as the sun's rays, 
blisters, etc. Symptomatic chloasma includes those forms 
which occur as a consequence of organic or systemic disease, as 
in Graves' disease, Addison's disease, tuberculosis, syphilis, etc. 
The most important variety of this form is chloasma uterinum, 
due to disturbances, functional or organic, of the utero-ovarian 
system. Here the pigmentation is almost always on the face, 
sometimes forming a sort of mask. It may be quite extensive 
over body and limbs, especially when due to pregnancy. 

The causes of chloasma have been partly mentioned in de- 
scribing the varieties. Most cases coming under observation 
are utero-ovarian in origin. Anaemia, chlorosis, chronic indiges- 
tion, neurasthenia, nervous shocks, etc., may also be mentioned 
as causative. 

Pathologically, chloasma is merely an increase in the phys- 
iological pigment function. It is apparently under the influence 
of the nervous system and in some cases the supra-renal glands 
seem to play a part. Anatomically, increased deposit of pigment 
is observed having its seat partly or wholly in the mucous layer 
of the epidermis. 

Chloasma is to be distinguished from tinea versicolor, vitiligo, 
and chromidrosis. In tinea versicolor the eruption is rarely 
met with upon the face and rarely occurs off the trunk and upper 
arms. It is scaly and a microscopic examination of the scales 
shows the fungus. In vitiligo the patches are dead white and it 
is only the surrounding skin which is darker than normal. In 



220 DISEASES OF THE SKIN. 

chromidrosis the fact that the glands are chiefly involved is 
ascertained by the secretion which covers the darkened skin. 

The treatment of chloasma requires a careful study of the 
case from every point of view. The condition of the general 
health, the digestion, the utero-ovarian functions should all 
be examined into. If anaemia or chlorosis are present these 
must be combated. Locally the treatment is somewhat simi- 
lar to that of lentigo, but rather more severe as the pigment tends 
to go deeper. Exfoliation of the skin is the result to be aimed 
at and this should be accomplished as thoroughly as the patient 
and circumstances will permit. Too strong exfoliatives as blis- 
tering, etc., must not be resorted to as deeper pigmentation may 
follow. The following preparation has been recommended: 
1$. Hydrarg. chlor corrosiv., gr. iij-xij (0.2-0.8); acid acetic 
dil, ~>ij (8.); sodii biborati, gr. xl (2.65); aq. rosae q.s. ad f§iv 
(128). Other preparations will be found in the text-books but 
in practice they mil be found either inefficient or uncontrolable. 
It must be admitted that as a general thing the treatment of 
chloasma is very unsatisfactory. 

ARGYRIA. 

Argyria is a form of discoloration of the skin, resulting from the prolonged 
administration of some salt of silver, usually the nitrate. The dose necessary 
to produce the effect is uncertain. As little as 280 grains (16.) taken over a con- 
siderable period has been reported as causing the discoloration. The earliest 
sign is a dark blue line along the edges of the gums. The color of the skin 
resulting is of a bluish-gray or slate color. It is general over the surface but 
most pronounced over the parts exposed to the light, as the face and hands. 
The hair and nails are also discolored, the hair having a faint reddish tinge. 

The pigment is found in the form of reduced silver, chiefly in the upper- 
most papillary layers of the corium. It is also observed in the membrana 
propria of the sweat glands. A deposit is also found in the internal organs 
with the exception of the nervous system. 

When once established the discoloration is permanent. Yandell had two 
patients in whom the discoloration disappeared under the use of iodide of po- 
tassium. In other cases, however, this has failed. 

TATTOO MARKS. 

Tatooing, or the mechanical introduction of pigments under the skin, is a 
well-known process. The pigments employed are carbon, cinnabar, carmine 



N^VUS PIGMENTOSUS. 221 

and indigo. The substances once introduced it is usually not long before the 
subject is anxious to get rid of them again. Most methods employed involve 
the production of a reactive and destructive inflammation which results in the 
formation of a crust which may be cast off, taking the pigment with it. 

Brault's method consists of cleansing thoroughly the surface and tattooing 
in a solution of 30 parts of zinc chloride in 40 parts of water; mild inflamma- 
tory reaction ensues, a crust forms and, after some days, falls off leaving a 
scar. Repetition is sometimes necessary. 

Variot's plan is, first to put on the mark a concentrated solution of tannin, 
which is then tattooed in, making punctures close together; he then rubs a 
stick of silver nitrate firmly over the surface, allows it to remain for several 
minutes and then wipes it off. A crust forms as before. The cicatrix is said to 
be scarcely visible. Ohmann-Dumesnil, Nelson and Skillern have successfully 
used glycerole of papoid, spreading it upon the surface and driving it in with a 
bunch of needles. Caroid has recently been employed with greater success. 

Small spots may be removed by means of the electrolytic needle or the cu- 
taneous punch. 

Gun-powder stains are practically the same as tattoo marks, and are to be 
removed in the same way. 

N^VUS PIGMENTOSUS. 

Ncbvus pigmentosus, or mole, is a circumscribed increase in the 
pigment of the skin, usually associated with hypertrophy of one 
or all the cutaneous structures, especially of the connective 
tissue and hair. 

There are several varieties of pigmentary naevus, named usu- 
ally from the predominant characteristics, naevus spilus, naevus 
pilosus, naevus verrucosis and naevus lipomatodes. 

Ncbvus spilus is the ordinary mole. The usual seats of these 
growths are upon the face, the neck, the chest, the back of the hand, 
and the shoulders. Moles vary in color from the natural shade 
of the skin to dark brown or black. They are usually very small, 
from pin-head to small-pea size, but they may at times cover 
considerable areas of the surface. They may be quite smooth 
or covered with fine or coarse hair. Hairs are more apt to be 
met with in hypertrophic pigmentary naevi. 

Sometimes pigmentary naevi approach the color of vascular naevi 
on account of the numerous enlarged blood-vessels which they 



222 



DISEASES OF THE SKIN. 



contain. The boundary line between the two is not accurately 
defined. 

Moles are extremely common. There is scarcely any one 
who has not one or more in some part of the person. It is 
only when they occupy a conspicuous position, however, that 
the physician is called upon to treat moles, unless in cases where 
they are of such size or so inconveniently placed that their re- 
moval is desirable for convenience sake. 

Moles are more frequently found on the insane and in per- 
sons who suffer from some hereditary taint. 





Fig. 30. — Nasvus Pigmentosus or Hypertrophicus. 

The larger pigmentary nasvi present very often curious shapes 
and sizes (naevus spilus, hypertrophic variety). 

Ncbvus pilosus is the hairy mole which, in addition to the com- 
mon, smooth mole just described, presents an abnormal growth 
of hair light or dark and usually coarse in structure. Ordinarily 
these are small but they may cover a considerable portion of 
the body. Occasionally they assume the curious configuration 
of a pair of hairy swimming drawers as in the illustration. 



NMVUS PIGMENTOSUS. 



22' 



Ncbvus verrucosus is the warty, pigmented naevus with a 
soft or hard, mamillated, rough surface, showing increase of all 
of the skin tissues, with often marked hypertrophy of the papillae 
giving rise to a furrowed, uneven surface. 

Ncbvus lipomatodes is the type in which 
there is an excessive fat and connective 
tissue hypertrophy with smooth or hairy 
surface and sometimes resembling mollus- 




cum. 

Occasionallv 



pigmentary naevi are ar- 



ranged in narrow bands, limited to one 
side of the body, forming the type known 
as linear ncevus, naevus unius lateris, etc.* 
Moles are seen in both sexes and are usu- 
ally congenital, though small ones may ap- 
pear at any time of life. 

Pathologically the ordinary pigmented 
naevus is similar to a freckle except that it 
is larger with often a slight connective tissue 
hypertrophy. In the other varieties there 
may be hypertrophy of all parts of the 
cutaneous structures. 

Pigmentary naevi sometimes form the 
place of origin of malignant growths, much 
less frequently than warts, however. 

The smaller moles may be destroyed by 
applications of nitric acid or caustic potash, 
the latter to be used with great caution, if 
the solid stick is employed, because of its 
tendency to spread in the surrounding 
tissues. The electro-cautery may also be 
employed. A scar may be expected in all 
but the most superficial pigmentary naevi after any operation. 
When there are hairs implanted in the naevus, electrolysis 

*See D. W. Montgomery, "The Cause of the Streaks in Naevus Linearis," 
Jour. Cutan. Dis., 1889, p. 132. Also Hyde, Rare Forms of Congenital . . . 
Naevus, etc., Chicago Jour, and Med. Exam., 1877, vol. xxxv, p. 377. 



Fig. 31. — Naevus Pilosus. 
(After Schii'immer.) 

The figures k n represent 
small, hairy moles, grep- 
resents a more angiomat- 
ous condition. 



224 



DISEASES OF THE SKIN. 



applied to these is the preferable method; while the hairs are 
being destroyed the mole is likewise being removed, and often 
may be nearly or entirely obliterated by this procedure. In 
larger naevi operation with the knife may be required. 




Fig. 32. — Naevus Lipomatodes. 



ACANTHOSIS NIGRICANS. 

Acanthosis nigricans is a rare disease of the skin, characterized by general 
pigmentation of a yellowish or brownish color, together with the formation 
of verrucous elevations at various points. 

The disease develops slowly or rapidly, the discoloration showing itself 
chiefly about the flexures and other sites of the papillomatous growths. The 
verrucous growths are most numerous and highly developed in the axillary, 
genito-crural, anal and abdominal regions, being at times developed to a 
highly hypertrophic, warty mass fissured deeply in the natural lines of the 



CLAVUS. 225 

skin. Keratosis of the palms and soles is usual. Occasionally the mucous 
membranes are affected. Dystrophy of the hair and nails is frequent. The 
disease tends to a fatal termination in some months or years by cancerous 
affection of some internal organ. 

The majority of the cases observed have been under twenty years of age . 

In one case supra-renal extract has seemed to do good. Otherwise, treat- 
ment has only proved palliative and the prognosis is unfavorable. 

CLAVUS. 

Clavus, or corn, is a small, circumscribed, conic, deep-seated, 
horny formation usually seated about the toes, with the small 
end of the growth pressing down upon the corium. 

A corn resembles a callosity in consisting of thickened, horny 
epithelium, but differs in being smaller and circumscribed, 
averaging a pea in size and being provided with a central prolong- 
ation or horny peg, known as the core. 

Two varieties of clavus are recognized, the hard corn, occur- 
ring on the dorsal surface of the toes or other external parts 
subjected to pressure and rubbing, and the soft corn, occurring 
between the toes and which is depressed in the center, of a gray- 
ish color and more or less macerated on the surface from heat 
and moisture. Occasionally suppurative action takes place be- 
neath the corn and when neglected or badly treated it may 
become the starting point of eryispelas or other infection. 

Although corns usually occur from pressure and friction, simi- 
lar growths have been observed when this cause could not have 
obtained. The corium beneath the down-pressing apex or core 
is thinned and the papillae are usually atrophied though they 
may be hypertrophied around the margin. Structurally the 
growth is made up of closely packed epidermic cells arranged 
in concentric layers. 

The treatment of corns consists in the first place in re- 
moval of the cause. The shoes must be made to fit properly 
or the corn, even if completely removed, will return. In 
addition felt corn plasters may be temporarily employed. The 
corn should be soaked in hot water and scraped with a 
15 



226 DISEASES OF THE SKIN. 

moderately sharp knife previously sterilized by alcohol or 
passing through a flame. Corns are sometimes pared with a 
razor, an extremely hazardous procedure and which is sometimes 
fatal. A good chiropodist working with aseptic instruments 
should always be employed if more than a slight scraping is 
required. After the external epidermic overgrowth is some- 
what removed the following paint is often employed: 1$. Acid 
silicylic, gr. xxx (2.); ext. cannabis indicae, gr. x (0.65); collodii, 
flexilis, aa fgj (4.) M. This is to be painted on the corn 
night and morning for several days, at the end of which time 
the parts are soaked in hot water and the horny mass or part 
of it will, as a rule, come readily away with a little rubbing 
or scraping. Personally I prefer to use the ten per cent, or 
forty per cent, salicylic " paraplastes " of Unna which can be 
procured through German importers. These are rubber plas- 
ters impregnated with the medicament and which have a wonder- 
fully softening effect when kept in contact with the corn for a 
day or two. Care should be taken to cut the plaster small enough 
not to extend beyond the boundary of the corn as its effect on 
the thin epidermis is very strong. 

In soft corns the important point is to separate the toes by 
cotton or wool so as to prevent maceration. The corn itself 
may then be touched with a nitrate of silver stick or a drop of 
tincture of iodine or nitric acid may be carefully applied. The 
latter is best but should only be employed in skilful hands, the 
surrounding skin being so thin and tender that any overflow 
may cause violent inflammatory reaction. When the soft corn 
is exceedingly sensitive dilute lead-water may be applied. 

CALLOSITAS. 

Callositas, sometimes called tylosis, is a hard, horny, thickened 
epidermic patch, due to hyperplasia of the stratum corneum 
and occurring for the most part on the hands and feet. 

Callosities consist of small or large patches of excessive epi- 
dermic accumulation, usually seen on parts subject to pressure 



KERATOSIS PALMARIS ET PLANT ARIS. 227 

or friction but which are also sometimes caused by chemical 
irritants. The palms soles, fingers, and toes are favorite loca- 
tions, but they may occur at any point where the skin has to 
protect itself from external violence by throwing out excessive 
horny epidermis. Sometimes callosities occur as the result of 
the prolonged administration of arsenic. They are not to be con- 
founded with the patches of keratosis palmaris et plantaris (g. v.). 

Anatomically, the growths consist in the thickened upper 
epidermic layers. The deeper strata of the skin remain as a 
rule unaffected. 

The treatment consists in the removal of the cause, in soften- 
ing of the skin in hot water, scraping and the application of sali- 
cylic acid plasters or " paraplastes " as described under clavus. 

KERATOSIS PALMARIS ET PLANTARIS. 

Keratosis palmaris et plantaris, sometimes called tylosis or 
ichthyosis of the palms and soles, is an hypertrophy of the corn- 
eous layer of these parts, usually of a more or less horny and plate- 
like character. 

The disease is usually congenital. In severe cases the whole 
palmar and plantar regions are the seat of a thickened, usually 
smooth, hardened, and sometimes seemingly translucent, yel- 
lowish, brownish-yellow, or yellowish-gray, calloused epidermic 
plate. The disease is usually limited strictly to the palm and 
sole but may sometimes extend a little beyond and occasionally 
involves the knuckles. The nails are slightly tilted upwards 
and thickened by underlying thickened epidermis. At the edge 
of the thickening there is usually a pinkish or reddish areola 
or zone. In some instances there is associated hyperidro- 
sis of the parts, in which the epidermic mass is still tough but 
sodden and not horny. There may be a generalized ichthyosis. 
Cases of keratosis of varying character differing from the type 
above described have been reported by several authors. 

The disease is almost always congenital, though acquired 
cases have been described, and it is not unfrequently hereditary 



228 DISEASES OF THE SKIN. 

in a few cases for two or more generations. Pathologically 
the disease is closely allied to callositas, the constant factor being 
the thickening and hardening of the skin. 

The only disease for which keratosis palmaris et plantaris 
is likely to be mistaken is the condition produced by arsenic 
and, therefore, the history of any given case is important. 

Treatment cannot, of course, remove the disease, but it may 
ameliorate the symptoms. Local measures alone are of value 
and, of the applications, those containing salicylic acid are most 
active. A strong plaster, ten per cent, to twenty per cent, alone 
or with soap plaster may be used, the skin being previously 
softened by prolonged baths and soakings in strong soapsuds. 
Occasionally ten per cent, to thirty per cent, caustic potash so- 
lutions may be used cautiously. The Rontgen rays have some- 
times been employed with benefit. 

KERATOSIS SENILIS. 

Keratosis senilis is the term applied to the somewhat hard, 
generally small, thickened epidermic patches found on the skin 
in old age. The term is also applied to the sebaceous warts 
found under the same circumstances. 

The skin in old age shows, on the one hand, a tendency to 
atrophy and, on the other, to the development of hypertrophic 
epidermic and pigmentary growths including the so-called sebor- 
rheic warts. These are greasy or crusted patches usually pea 
to bean size or larger which when scraped reveal a slightly raw 
or bleeding surface. The scaliness increases in thickness and 
sometimes in area, and from such a crust or degenerative sebor- 
rheic patch an epithelioma occasionally results. In different 
lesions the seborrhceic or the warty element may predominate. 

The usual site of these formations is the face but they may 
occur upon any part of the body. The back is often the seat 
of great numbers of lesions. They usually begin to show them- 
selves between the ages of fifty and sixty but may occur earlier. 

If attended to in time the prognosis of keratosis senilis is favor- 



KERATOSIS PILARIS. 229 

able but their chief significance is the possibility or probability of 
development into epithelioma. 

In their earliest appearance frequent and vigorous washing 
with some good toilet soap, as with sapo viridis or one of the 
medicated soaps of Eichoff or Stiefel, will encourage the normal 
exfoliation of epidermis and prevent, to some extent, the abnor- 
mal epithelial formation. When fully developed, however, 
the best plan of treatment is destruction by a caustic of mild, 
medium or intense strength. Glacial acetic acid, trichloracetic 
acid or strong solutions of bichloride of mercury will remove 
threatening pigmentary spots or commencing keratoses. When 
fully developed seborrhceic warts exist, fuming nitric acid may 
be employed with due care, or in the more hypertrophic condi- 
tions and where the warty character is more highly developed 
it may be necessary to use solutions of caustic potash or even the 
solid stick. When numerous keratoses are spread over a wide 
surface, as the back, excellent results maybe obtaned with theRont- 
gen ray. 

KERATOSIS PILARIS. 

Keratosis pilaris is a hypertrophic affection characterized by 
the formation of pin-head-sized or slightly larger conic epider- 
mic elevations seated about the apertures of the hair follicles. 

In its mildest form this affection is seen on the backs of the 
arms and on the thighs, in the form of numerous minute, dry, 
horny growths, of the color of the surrounding skin, looking 
like "goose flesh." The hairs growing from these elevations are 
usually atrophied or curled up in their follicles. In the more 
marked forms of the disease a well-marked, hard, pin-head- 
sized papule is observed, which may be of various shades of 
red or brown. Sometimes the lesions become hypertrophied 
to the size of acne papules. The color usually disappears 
more or less upon pressure. In these forms of keratosis pilaris 
the hair disappears entirely or is broken off short at the surface. 
Keratosis pilaris is usually unaccompanied by any sensation, 
but at times there is considerable pruritus. 



230 DISEASES OF THE SKIN. 

The affection is more common in early adult life. It is most 
usually observed during the winter months and in those having 
naturally a dry skin. It is often observed in connection with 
ichthyosis. 

Anatomically the disease consists of a hyperkeratinization 
of the upper part of the pilo-sebaceous follicular outlet, and 
the papular elevation results from the formation of this super- 
abundant or accumulated horny mass which projects beyond the 
orifice. In some cases slight inflammatory appearances coexist. 

The affection is to be distinguished from the miliary papular 
syphiloderm and from lichen scrofulosus. The dull ham- 
brownish red papules of syphilis have a more general distribution, 
are more infiltrated and firmer to the touch and tend to distribu- 
tion in groups. Other symptoms of syphilis are also apt to be 
present. In lichen scrofulosus — a rare disease — the eruption 
is usually limited and occurs in distinct, more or less rounded 
groups or patches, and most commonly upon the trunk, especially 
the abdomen. The extensor surfaces of the limbs are rarely 
involved. " Goose flesh" which this disease resembles ai first 
glance is a transitory condition. 

The treatment is largely local. Warm baths with the use of 
toilet soap or sapo viridis are to be followed by inunctions with 
a mild salicylic ointment (2 per cent, to 6 per cent.). Soda bicar- 
bonate or borax baths are also useful. 

KERATOSIS FOLLICULARIS.* 

Keratosis jollicidaris, called also ichthyosis follicularis, Darier's disease, 
psorospermosis, acne sebacee cornee and by various other names, is a rare 
affection characterized by the appearance of small, horny elevations, at first 
not unlike the lesions of keratosis pilaris, but later consisting of greasy-look- 
ing papules or dry, firm, brownish papular elevations semi-globular in shape 
and small to large pin-head size, disseminated over the involved area. In 
the center of the large lesions is usually a firm, hard or fatty-looking mass 
or plug. The disease is usually most abundant about the face, scalp and 
chest, loins, genito-crural regions and the extremities. It may in time be- 

* Bowen, Jour. Cutan. Dis., 1896, p. 209, gives a complete account of this 
disease. 



VERRUCA. 231 

come generalized. On the scalp there is usually a thick seborrhceic crust 
but no loss of hair. When grown larger and confluent the surface may pre- 
sent a nutmeg grater or papillomatous appearance. There may be consid- 
erable itching. 

The disease centers about the hair follicles and is in fact a keratosis of the 
mouths of the pilo-sebaceous ducts. The psorosperm as a cause is no longer 
considered. 

The disease is persistent and usually slowly progressive. It does not af- 
fect the health. Though incurable it may be ameliorated by frequent bath- 
ing and the application of softening ointments, as those containing salicylic 
acid, sulphur and resorcin. 

Keratosis jollicularis contagiosa is a rare affection, usually occurring among 
children, characterized by a slight thickening of the horny layer with an ac- 
centuation of the cutaneous furrows and a yellowish to yellowish -black dis- 
coloration. Later black points developing into papular elevations containing 
projecting horny processes are observed. The regions affected are usually 
the neck, trunk, extensor aspects of the extremities, and less commonly the 
face and flexor surfaces. The affection is said to respond readily to soften- 
ing and alkaline applications.* 

VERRUCA. 

Verruca, or wart, is a small, circumscribed, epidermal and papil- 
lary growth which may be soft or hard, and rounded, flat, acumin- 
ated or filiform. 

For convenience' of description warts may be divided into 
several clinical varieties. 

Verruca vulgaris, the common wart, occurs chiefly upon the 
hands, it is large pin-head to pea-sized or larger, round and with 
a broad base. It is generally hard, somewhat elevated, flattened 
and circumscribed. As a rule it is of slow and gradual growth. 
The surface is at first smooth but later becomes rugous. The 
color is at first that of the natural skin, later it may become 
yellowish, brownish or even black. Usually there are one or 
several present but at times they are very numerous. They 
occur chiefly among the young. Sometimes a single lesion, the 
"mother wart," appears followed later by several others. 

While this form of wart is more common upon the hands it 

* Brooks, International Atlas, 1892, part vii, plate xxii. 



232 DISEASES OF THE SKIN. 

may occur on the forehead and elsewhere. Occurring on the 
sole it has received the name verruca plantaris and is occasionally 
mistaken for corns. It may give rise in this locality to con- 
siderable pain and inconvenience. Now and then this form of 
wart is found upon the vermilion of the lips. 

Verruca plana occurs in older persons in the form of pea to 
finger-nail sized, flat growths, very slightly elevated, occurring 
about the face, forehead, shoulders, etc. They are usually of a 
dark color and become in time papillomatous on the surface 
and covered with a sebaceous crust which is shed or rubbed off 
from, time to time {verruca sebacea). They sometimes resemble 
moles and with the various degenerative epithelial and pig- 
mentary changes of the skin are characteristie of old age. 

Verruca plana juvenilis are peculiar lichen-planus-like warts 
with roundish, square or polygonal base, flat, smooth and usually 
situated upon the face, where they may be few or many in number. 
Occasionally there is a slight central depression. They are 
normal skin color, grayish or brownish. The chin, the lower 
part of the cheeks and the forehead toward the temporal region 
are the favorite seats. They are slow and insidious in their 
coming and may last for years. 

Verruca digitata is the name given to a form of wart where 
the lesion is cleft or like fingers. The base is solid and often 
somewhat constricted. These warts are horny toward the ends 
of the digitations but soft at the base. They bleed more readily 
than the flat warts. They are pea-size or occasionally larger, 
and are most prone to occur upon the scalp. A variety of these 
are the filiform warts, verruca filiformis, growing from the skin 
like a single short thread. These are most apt to occur about 
the neck. 

Verruca acuminata, condyloma acuminata, venereal wart, 
cauliflower excrescence, is a variety of wart usually occurring 
on the mucous and muco-cutaneous surfaces of the genital and 
anal regions. They may occur also in the mouth and tongue 
and even in moist folds of the skin as the axillae and groins. 
The growths are pointed or flattened, single or numerous. They 



VERRUCA. 233 

usually show a pinkish or reddish color. They sometimes re- 
semble a cock's comb. In extreme cases, especially about the 
female genitals, these warts grow luxuriantly, forming cauliflower- 
like masses. When seated in a moist region they are apt to secrete 
a yellowish, puriform fluid, decomposing readily and giving rise 
to a peculiarly offensive odor. They are apt to be found about 
and within the genitals of prostitutes suffering from gonorrhoea. 
In the male they occur about the sulcus of the glans penis. 
They tend to increase and extend. 

Warts are usually considered contagious. The verruca 
acuminata are unquestionably so and are also auto-inoculable. 
Inoculation experiments in ordinary warts seem to indicate a 
period of incubation extending over one to several months. 

The initial factor in the production of a wart is a break or 
fissure of some sort, probably permitting a microbic invasion which 
causes irritation, and, following this, hypertrophy of the epidermis 
and papillae with some increased connective tissue and capillary 
overgrowth. Verruca acuminata is largely made up of con- 
nective tissue elements with marked papillary hypertrophy, 
excessive development of the rete and an abundant vascular 
supply. The horny layer is often almost or completely wanting. 

Warts are not often confounded with other affections but the 
juvenile variety is to be distinguished from lichen planus which 
it sometimes resembles. The latter, however, rarely occurs 
on the face, the lesions are apt to be squarish in shape and have 
a slight depression in the center and often a fine glistening scale. 
Warts on the sole resemble callosities but on cutting or shaving 
them down the wart-like structure can be perceived. Warts 
about the tips of the fingers are to be distinguished from verruca 
necrogenica or dissection tubercle. I have seen in one case a 
wart-like lesion on the tip of the forefinger turn out to be the 
initial lesion of syphilis. 

As the microbic element is at the bottom of the verrucous 
growth, antiseptic and parasiticide applications are likely to 
be of service. 

The affected localities should be frequently washed with a 



234 DISEASES OF THE SKIN. 

bichloride of mercury soap, and when the warts are numerous 
and closely placed together, a solution of the bichloride (1-2000) 
may be applied from time to time to advantage. This treat- 
ment should precede and accompany the use of other remedies. 

Small digitate and filiform warts may be clipped off with 
curved scissors, the base being touched with nitrate of silver 
stick. The dermal curette or scraping spoon may be employed 
in the flat ones. The ligature, escraseur, or galvano-caustic 
wire may be employed in the larger, peduncula:e variety. Con- 
dylomata about the female genitals and anus and elsewhere are 
best treated by washing the parts with dilute liquor sodae chlorin- 
atae, and afterward dusting the surface with powdered calomel, 
resorcin, or a powder composed of equal parts of burnt alum 
and savin. 

Perhaps the best treatment of condylomata consists in frequent 
bathing with bichloride of mercury solution (1-2000) and dust- 
ing the parts with a powder composed as follows: 

J^. Pulv. sabinae, 

Pulv. acidi salicylici, aa oiv. (16.) M. 

Glacial acetic, nitric, chromic, or carbolic acids may also be 
used. The larger condylomata may be attacked by the electric 
cautery. Common warts may be cauterized by one of the acids 
mentioned, or by means of caustic potash, in stick or solution. 
These more severe measures should not, however, be resorted 
to unless the milder applications fail. The following prescrip- 
tion answers in many cases: 

1$. Ext. cannabis indicae, gr. x ( 0.65) 

Acid salicylici, 3ss ( 2. ) 

Collodii, Bj. (32. ) M. 

Apply daily, for three or four days, and then scrape the wart, and, if neces- 
sary, apply again. 

Other collodions which may be used are these : 

ly. Acidi salicylici, gr. v-xxx ( 0.30-2.) 

Alcoholis, f 5ss ( 2. ) 

^theris, ' f 5ij (8. ) 

Collodii flexili, ad £5iv. (16. ) M. 



CORNU CUTANEUM. 235 

Or: 

ly. Acidi salicylici, 

Acidi lactic ; aa 5ss (2. ) 

Collodii flexili, f 3iv. (16. ) M. 

Another useful preparation is the following: 

1$. Acidi salicylic, 3ss ( 2. ) 

Emplast. hydrarg., 

Ung. hydrarg., aa oiv. (16. ) M. 

Fiat, emplastrum. 

This is kept constantly in contact with the wart for about 
a week. The epidermis becomes macerated and can be sepa- 
rated from the cutis while the warts crumble away. 

The salicylic rubber plaster of Johnson and Johnson is also 
an excellent application. It softens the wart, which can" then 
be scraped off. 

The following is an excellent, although very energetic, applic- 
ation. It should be employed with caution, care being taken 
that the effect does not extend too far: 

1$. Hydrarg. bichlor., gr. iv-viij ( 0.24.-48) 

Collodii flexili, l&v. (16. ) M. 

Now and then warts resist all treatment, or spring up as fast 
as removed. In such cases arsenic may be given with some hope 
of preventing the recurrence of the growths. It should be admin- 
istered in the form of Fowler's solution in the dose of two to 
four minims thrice daily. Magnesium sulphate in doses of 
from 10 to 20 grains (0.65-1.30) morning and evening may also 
be employed. The tincture of thuja occidentalis in doses of 20 
drops to 2 drachms (1.33 to 8.) three times a day may be employed. 
Occasionally the presence of warts seems due to some nervous or 
constitutional influence, and they stubbornly resist all treatment. 

CORNU CUTANEUM. 

Horns in the human being are of the same nature as those of 
animals although they grow from the skin, whereas the horns 



236 



DISEASES OF THE SKIN. 



of animals are always implanted in bone. They are usually 
single, although at times multiple, in one or two cases recorded 






Fig. 33. — Cornu Cutaneum. Multiple. (After Bat ge.) 

they have been numerous. They are solid, laminated or fibril- 
lated, hard and dry, grayish, yellowish, brown or black in color, 



CORNU CUTANEUM. 



237 



generally twisted or bent, except when quite small. Horns 
usually vary from 2 mm. to 6 mm. in diameter and 5 mm. to 
2 cm. in length, but some have been reported of considerable 
size, up to 5 cm. in circumference in one case and in another 4 
cm. in length. Their growth is usually slow but variable and they 




Fig. 34 — Cornu Cutaneum. (After Pancoast.) 
Photographic Rev. Med. and Surg., 1870-71, vol. i. 



may either drop off or be knocked off, exposing a red, raw sur- 
face from which another is liable to be produced. 

Horns are apt to occur in old age; they are rare before forty 
but have been seen in infancy. The majority start from seba- 
ceous cysts or from sebaceous warts, or, it is said, from scars 
or occasionally from epitheliomata. They are essentially hyper- 
trophic horny warts. They arise from the deeper layers of the 



238 DISEASES OF THE SKIN. 

stratum mucosum. The papillae are hypertrophied and the 
growth is situated on the papillae, groups of which extending 
into the horny mass have been observed. The horny formation 
itself consists of agglutinated epidermic cells forming small col- 
umns or rods. 

The treatment of horns is simple. The growth is to be soft- 
ened by poultices or wet dressings and twisted off and the base 
thoroughly burned out with caustic as epithelioma is apt to de- 
velop sooner or later. Larger horns must be cut out completely. 

ICHTHYOSIS. 

Ichthyosis is a congenital, chronic, hypertrophic disease, usu- 
ally occupying the whole surface, characterized by dryness, harsh- 
ness, or scaliness of the skin and a variable amount of papil- 
lary, growth. Two varieties are generally described, I. simplex 
and I. hystrix. Ichthyosis simplex may be so mild in form as to 
amount to little more than a certain dryness and roughness of 
the skin. It may, on the other hand, be quite severe. As 
ordinarily met with, ichthyosis simplex consists of an altered state 
of the skin, characterized by a harsh, dry condition of the whole 
surface, accompanied by the production of scales, sometimes 
fine and branny, at other times coarser, and shaped after the 
lines and furrows of the skn. The latter, from their resem- 
blance to fish scales, have given occasion to the name of the 
disease, "ichthyosis," or the " fish-skin" disease. The amount of 
scales depends upon the age of the patient, the severity of the 
disease, and the efficiency of any treatment which may have been 
employed. The scales, if not removed by frequent bathing, tend 
to accumulate. They are usually whitish, grayish, or yellowish 
in color, with sometimes a glistening look. Occasionally the 
general color of the eruption is of a more or less yellowish or 
dark olive green. Even when the disease is not severe, it gives 
the surface an unwashed look. 

The localities in which ichthyosis is developed to the most 
marked degree are the lower extremities, from the hips to the 



ICHTHYOSIS. 239 

ankles, and the arnib and forearms. The skin of the backs of 
the hands and the face often has a peculiar, smooth, drawn, 
parchment-like appearance, which is very characteristic. Sen- 




Fig. 35. — Ichthyosis. (After a model by Baretta.) 



sible perspiration is, in most cases, absent, excepting in the face, 
axillae, palms, and soles. There is sometimes marked hyperidro- 
sis in the two last. The disease is worse in winter than in sum- 



240 DISEASES OF THE SKIN. 

mer; in mild cases it is apt to almost disappear during the latter 
season. The course of the disease is essentially chronic. Begin- 
ning to show itself distinctly during early childhood, it grows 
more and more marked with each year of the patient's life. It 
sometimes appears to be hereditary, but no distinct and invari- 
able hereditary influence seems to prevail in all cases. Ichthyo- 
tic parents usually beget healthy children. The patient him- 
self generally enjoys fair or good health. The disease occurs in 
all races, both sexes, and in every grade of society. 

The pathological changes observed in ichthyosis were originally 
considered seated essentially in the epidermis, but now they are 
thought to originate in the connective tissue chiefly of the corium. 
The epidermis is thicker than normal with increased formation of 
epithelial scales and a heightened tendency to cornification, the 
process of exfoliation being slowed. Degenerative changes are 
also observed in the coil and sebaceous glands. 

The diagnosis of ichthyosis is usually not difficult. The his- 
tory alone differs from that of all other skin diseases, its chronic- 
ity offering a marked contrast to the rapidly developing char- 
acter of the acute inflammatory disorders. 

Internal treatment is ineffectual, or nearly so, in many cases 
of ichthyosis, so far as the complete cure of the disease is con- 
cerned, but much can be done to ameliorate the patient's condition, 
and toward preventing entire atrophy of the cutaneous glands. 

Arsenic and cod-liver oil should be administered separately or 
together. A pill, containing -%-$ grain (0.002) of arsenic, three times 
a day, may be given with propriety to adults, but the dose must be 
proportioned to the idiosyncrasy of the patient. It should be 
continued in courses of several months with intervals. Cod- 
liver oil may be given pure and alone, in the form of emulsion or 
in capsules. There may be cases in which jaborandi or pilo- 
carpine may be employed for short periods, but this drug is so 
apt to disagree that it should rarely be employed.* 

As regards the external treatment, this should be active and 

* See excellent article on treatment, by Unna, Monatshefte, /. Prakt. Dermatol., 
1883, p. 196. 



ICHTHYOSIS. 241 

continuous. The skin is to be kept moist and supple by the fre- 
quent administration of warm baths with alkalies or soap. 
Vapor baths are also useful. Inunctions of some emollient 
material should always be practiced after the bath. In well- 
marked and severe cases the soap treatment will be found valua- 
ble to remove some of the dry and horny epidermis and prepare 
the way for the application of emollients. A sufficient quantity 
of sapo viridis is to be rubbed into the skin twice daily for four 
to six days, during which period the patient is to refrain from 
bathing. A bath is first to be taken four or five days after the 
last rubbing, when, in fact, the epidermis has begun to peel off; 
afterward, inunction with a simple ointment is to be practiced, 
in order to prevent Assuring of the new skin. For this purpose, 
oil of sweet almonds, glycerine, pure or diluted, with one to seven 
parts of water, or one of the following ointments may be used : 

J^. Adipis benzoat, giv (128.) 

petrolati, 5j ( 32.) 

Glycerinae, 5 j- ( 4-) M. 

Sulphur has been very highly extolled as a remedy in ichthy- 
osis. It has been employed in the form of ointment in the 
strength of half a drachm to a drachm to the ounce, and more 
recently by impregnating the underclothing with sulphur, hang- 
ing it in a box, and vaporizing flowers of sulphur on a hot — not 
too hot— plate. The clothing should be reimpregnated every 
five or six days. 

The following ointment is recommended by Brocq: 

I}. Acid, salicylici, 9ij-iv ( 2.6 to 5.32 ) 

Sulphur praecipitat., 5iij (12.) 

Glycerinae, 

Lanolini, aa oij- (64.) M. 

Another formula recommended by Brocq is this: 

1^. Acid, salicylic, 
Acid, tartaric, 

Resorcini, aa 5 j (4.) 

Sulphur, praecipitat., oijss (10.) 

Adipis, oj (32.) 

Lanolini, §iij. (96.) M. 

16 



242 DISEASES OF THE SKIN. 

These ointments should be well rubbed in every evening 
and removed with soap in the morning. 

Ichthyol ointment may be useful in some cases, as follows: 

1$. Ichthyolis, oij-iv ( 8. to 16.) 

Acidi salicylici, 5j ( 4-) 

Sulphuris praecip., 5ij ( 8.) 

Adipis, §iv. (128.) M. 

To be applied at night and washed off next morning with 
ichthyol soap. 

The prognosis of ichthyosis is entirely unfavorable as regards 
v . . permanent cure, but alleviation of the 

. N symptoms may be brought about very 

jS satisfactorily. The affection should 
really be regarded as a deformity 
~idM& rather than a disease, though it pre- 
disposes strongly to the occurrence of 
l£jr* eczema, particularly of the hands. 

,J Ichthyosis Fcetalis. Infants affected 

>J>* ''y this peculiar condition sh^w at 

^f% birth a thick, hard, resistant epi- 
dermis, without elasticity. The skin 
is covered with dried sebum; it has 
a dirty yellow color, is hard, rigid, and 
deeply fissured at all points, owing to 
the effect of the infant's growth dur- 
ing foetal life upon its inextensible 
j0 integument. 

■:f The mouth is widely opened; the 

^■f infant can neither close it, nor can it 

jr take the breast. All the lines of the 

.. ^ face are obliterated; every movement 

Fig. 36. — Ichthyosis rcetahs.* J 

is made with difficulty. Even if the 
patient is born alive, it soon succumbs to inanition or to the 
exhaustion due to the splitting and suppuration of the numer- 
ous fissures. The etiology of the affection is not known. 

* I have unfortunately lost the reference to this case and therefore can not give 
due credit which I extremely regret. A. V. H. 




ICHTHYOSIS. 243 

Ichthyosis hystrix is characterized by the formation of irreg- 
ularly shaped and sized, ill-defined, rough, harsh, yellowish, 
brownish, or greenish patches, made up of enormously hyper- 
trophied, more or less horny papillae. Unlike the ordinary form 
of ichthyosis, this is apt to be localized, and rarely covers the 
surface to any extent. It is sometimes distributed in the line 
of the nerves. Sometimes the papillae are so hypertrophied as to 
stand out like porcupine quills — hence the name " hystrix." In 
ichthyosis hystrix, in addition to the changes noted in ichthyosis 
simplex, the direct transition from rete cells into horny cells, 
without intermediate change has been noted. The anatomical 
conditions resemble those observed in old warts, enormously 
elongated papillae, above which the horny layer is piled up in 
thick, stratified coats. There is a moderate cell infiltration of 
the papillae with dilated vessels. 

The treatment of ichthyosis hystrix is essentially that of any 
warty or horny, non-malignant growth. The patch, if not too 
large, may be poulticed until softened, and then attacked by 
caustic potassa or glacial acetic or chromic acid, or it may be re- 
moved by the knife. In one case considerable improvement was 
gained by painting the surface, twice daily, with the following: 

1$. Acidi salicylici .... oss ( 2. ) 

Ext. cannabis ind., gr. x ( 0.65) 

Collodii, gj. (32. ) M. 

The salicylic rubber plasters made by Johnson and Johnson 
and the "paraplastes" of salicylic acid made after Unna's form- 
ula in Germany prove useful in these cases. 

Another preparation which, it is said, has been used with good 
effect is the fluid extract of thuja occidentalis, painted on in the 
same way. 

The prognosis of ichthyosis simplex and hystrix is unfavorable. 
A few cases have been cured it is said, but the utmost we can 
expect is amelioration of the various inconveniences caused by 
the disease. 



244 DISEASES OF THE SKIN. 

POROKERATOSIS. 

Porokeratosis is a rare variety of hyperkeratosis described by Mibelli, 
Wende.f Gilchrist J and others. The disease is slow and insidious, beginning 
as a trifling, superficial but slightly elevated, warty looking formation, or as 
thin callous spots which slowly enlarge, throwing out a sort of dyke or 
rimmed edge and leaving an atrophic, slightly callous center. The border 
shows occasional minute, wart-like or papillary concretions. It is often wavy 
or almost poly cyclic in outline. The enclosed atrophic area is dirty grayish - 
white, sometimes brownish or pinkish, while the raised border is brownish- 
gray, darker and well defined. 

The favorite seats of the eruption are the dorsal aspects of the hands and 
feet, but it may occur elsewhere The rings are one to several inches in 
diameter or smaller. 

The eruption has been thought parasitic and inoculable, but no positive 
proof has been adduced. The process is a hyperkeratosis affecting the 
lower horny and upper rete layers. The sweat glands are plugged with 
horny epithelium, and the hair follicles are involved. In the central area 
the papillary layer of the derma is almost obliterated. The treatment is 
not satisfactory. The electric needle has been used in some cases with 
success. 

ANGIOKERATOMA.? 

Angiokeratoma is an affection, usually of the extremities, occurring for the 
most part in those subject to chilblains, and characterized by the appear- 
ance of telangiectases which subsequently develop into warty elevations. 

The telangiectases usually follow chilblains, appearing as pin-point to pin- 
head sized lesions, discrete or crowded together. They are pinkish in color, 
later becoming darker or changing to purplish or reddish -brown. The backs 
of the fingers or the dorsal surface of the toes, especially towards the basal 
portions, are the favorite sites, although they may be found elsewhere. 
After a while slight elevation is noted and the surface may become rough, 
irregular and horny, presenting when the lesions are closely bunched the ap- 
pearance of warts, with telangiectases on them. The disease is apt to appear 
or to take on fresh action in cold weather. There are no subjective symp- 
toms. 

*Monatsh. j Prakt. Derm., Nov. 1893; International Atlas of Rare Skin Diseases 
Vol. iv., 1893., pi. xxvii; also Monatsh. f Prakt. Derm., 1895, vol. xx., p. 309. 

"\Jous. Cut. Dis., 1898, p. 505. 

%Bull., Johns Hopkins Hosp., 1897, p. 107 and Jour. Cut. Dis., 1899, p. 149. 

§See Cottle, St. George Hosp. Rep., 1877-8., vol. ix. p. 758, with colored illus- 
tration., Pringle, B. Jour. Derm., 1891, pp.- 237, 282 and 309.; Zeisler. Jour. Am. 
Derm. Ass., 1893 (abstract of paper); and Fordyce, Jour. Cut. Dis., 1896, p. 83, 
Plates, etc. 



SCLERODERMA. 245 

Anatomically the change is primarily a vascular one followed by keratosis 
as a secondary phenomenon. 

The disease is persistent with no tendency to involution. Electrolysis of 
each lesion has proved the best treatment. 

SCLERODERMA.* 

Scleroderma is a chronic disease characterized by a circum- 
scribed, localized, or general and more or less diffuse hardening 
of the integument, which is usually rigid, stiffened, indurated, or 
hide bound to a greater or less extent. 

Two varieties are usually described, the diffused and circum- 
scribed. 

Scleroderma diffusa is the affection described first under 
the name of scleremie des adultes, by Alibert, in 1817. 

The induration, which is so marked a symptom of the disease 
is variously described in different cases, and writers seem to vie 
with one another in their attempts to express vividly the peculiar 
sensations offered to the sight and touch. 

In some cases the skin is described as being of stony or board- 
like hardness, or feeling like that of a frozen corpse, without 
the sensation of cold. In other cases it is compared to brawn or 
leather. Adherence of the skin to subjacent tissue is not uncom- 
mon — "hide bound," or "perfectly immovable," are the expres- 
sions used. In a case coming under my own personal observa- 
tion, the skin over the forearms was so bound down that the 
limbs seemed as if carved out of wood. The underlying muscles, 
particularly those of the limbs, are generally more or less wasted. 

One of the most distinctive characteristics of this variety 
of scleroderma is symmetry and diffusion as distinguished from 
localization. Commencing, as in most of the cases reported, on 
the back of the neck, the disease spreads equally on either 
side of the median line; or, when it begins in the limbs, both 
are usually attacked at once. 

* For recent views and history see Colcott Fox, B. Jour. Dermatol., 1892, p. 
101; Lewin and Heller, Die Sclerodermic, Berlin, 1895, and Raymond, Clinique 
des Maladies de la Systeme Nerveux, 3me serie, p. 683, for the neurological point 
of view. Also Dercum, Jour. Nervous and Mental Dis., July, 1896. 



246 DISEASES OF THE SKIN. 

The surface covered is almost invariably large; those cases 
reported in which the disease seems to tend toward localization, 
are usually to be regarded as, in all probability, belonging to the 
other variety of the disease. 

A marked characteristic of this variety of scleroderma is that 
no distinct boundary exists to the affected areas; they seem to 
melt imperceptibly into the surrounding skin. 

The color of the affected skin varies much in different cases. 
In many cases pigmentation exists to various degrees, while 
in other cases the skin either retains its normal tint, or becomes 
pale-yellowish or waxy in color. A curious fact is that the pig- 
mentation seems much deeper in the immediate neighborhood 
of the sebaceous follicles. In a certain number of cases, it is 
said that spots or patches of pigmentation at various points pre- 
cede and presage the induration of the skin in these localities. 
This, however, is more likely to occur in the circumscribed and 
localized form of scleroderma. 

Neither fever nor local inflammatory reaction of any kind 
ushers in, accompanies, or follows the appearance of the disease 
in any typical case. (Edema is rarely, if ever, observed in diffuse 
scleroderma. Occasionally swelling of the hands or feet has 
been observed, as a result of mechanical interference with the 
circulation. 

The rapidity with which the disease attacks and spreads over 
the skin varies in different cases. In some, large areas of skin 
become indurated in a very short time; in others, the onset is 
slow and insidious. 

In no case is there any marked elevation of the indurated 
skin above the level of the surrounding and unaffected parts, 
though tubercular elevations have occasionally been observed. 
Where the tightened skin plays over prominent bony parts, as 
the knuckles, a tendency to ulceration is often observed. 

Cutaneous sensibility in most cases remains unaltered. The 
appendages to the skin, the glands and hair, are rarely affected. 

Scleroderma diffusa runs a very chronic course; many cases 
may be under observation for years, with little or no change 



SCLERODERMA. 247 

apparent, and this under the persistent employment of decided 
and varied treatment. The existence of scleroderma does not 
necessarily exclude that of other skin diseases; acne, comedo, 
and eczema have been observed simultaneously, and in the 
same localities. No previous ailment seems to exercise a predis- 
posing influence, unless it be rheumatism. The immediate cause 
in many cases has been exposure to dampness and cold. 

The pathological anatomy of scleroderma diffusa is simply 
that of a hyperplasia of the fibrous element of the papillary 
layer and corium, with decrease of subcutaneous fat and increase 
in pigment deposit. 

Scleroderma diffusa is not in itself a fatal affection. In the 
few cases in which death has occurred while the patient has been 
under observation, it has usually occurred from some intercurrent 
disease, totally unconnected with the scleroderma. It is true 
that, in one case recorded, death was hastened by the extremely 
inflexible condition of the facial integument, which interfered 
greatly with deglutition, while in some others respiration was 
much impeded through immobility of the thoracic walls. 

Scleroderma localis, (morphosa, keloid oj Addison) appears 
in typical cases, in the form of one or more patches, from one- 
half to two inches in diameter, coming gradually without sub- 
jective symptoms so that they may not attract attention until 
fully developed. Each patch is of irregular roundish, oval, or 
elongated shape, of a dead white or old ivory-white color, bor- 
dered with a narrow violet, lilac, or pink zone made up of minute 
blood-vessels. The patches are level with the skin, generally 
unilateral and often distinctly arranged in the course of a nerve 
area like herpes zoster. They may appear anywhere but are 
most usually seen on the breasts, head, and face, particularly 
in the line of the supra-orbital nerve, and most of all on the limbs, 
especially the lower limbs. As a rule, the skin over the patch 
feels like parchment and may be pinched up, but sometimes it 
is like a plate let into the skin. As the disease progresses the 
spots may sink below the level of the skin. The diseased area, 
when once developed, may remain stationary a long period and 



248 DISEASES OF THE SKIN. 

then gradually fade and the skin become normal. In other 
cases new patches may continue to form. The duration of the 
disease may be from one to ten years. 

Another form of localized scleroderma is the band form. 
Usually this consists of a single elongated, cicatricial looking patch, 
adherent to the subjacent tissues and forming a sulcus or raised 
into an irregular keloidal ridge. When slight, between the 
brows, as I have seen in two instances, a half to one inch shallow 
furrow extended up the center of the forehead into the hairy 
scalp. 

Ulceration sometimes occurs in morphcea and in other cases 
bullae are seen. 

Scleroderma localis is more common in females than males. 
People of neurotic temperament are more apt to have the disease 
and it is said to be the result, at times, of worry. Local irrita- 
tion also may be a predisposing cause. In the majority of cases 
no adequate cause can be assigned. Facial hemiatrophy is 
probably closely connected with this form of the disease. 

Scleroderma is supposed by some to be a neurosis, trophoneu- 
rosis or angioneurosis, by others the vascular system is said to 
be at fault, while still others attribute it to changes in the connec- 
tive tissue, especially its intercellular substance. 

The anatomical changes are chiefly in the corium and sub- 
cutaneous tissues. There is a marked increase in the connective 
tissue element with thickening and condensation. The fat 
atrophies and gives place to connective tissue. The vessels are 
diminished in caliber. The glandular structures are unchanged 
except in the later stages when they are atrophied. The his- 
tological changes in localized scleroderma vary little, it is said, 
from those of the diffused type in its early stage. 

The only form of scleroderma which is liable to be confounded 
with any other disease is the morphcea patch of the early localized 
form which resembles the white anaesthetic spots of leprosy, but 
differs in being normal in sensation, and vitiligo from which it 
differs in being something more than a mere transfer or absence 
of pigment. 



SCLEREMA NEONATORUM. 249 

The prognosis of scleroderma, except in the extreme forms of 
the diffuse variety, is favorable as regards its influence upon 
health and life. As a general thing, however, the affection tends 
to persist indefinitely. A few cases of both varieties are re- 
ported to have recovered. 

The treatment of scleroderma is very unsatisfactory for the 
most part ; change to a dry pleasant climate, avoidance of exposure 
to cold and dampness and all kinds of tonic and invigorating 
treatment are, of course, to be prescribed when possible. Mas- 
sage and the application of suitable stimulant applications are 
also in order. When drugs must be depended upon, arsenic, iron, 
quinine, strychnia and cod-liver oil may be employed. Some 
have gotten benefit from thyroid extract but the fact must be 
mitted that the disease usually takes its own course. In 
the cases which have come under my notice I have never 
seen any effect whatever produced by any remedy. I have seen 
some cases spontaneously improve with the lapse of time. 

SCLEREMA NEONATORUM. 

This rare affection is in no way connected with scleroderma, 
although- the latter was at one time called "sclerema of adults." 
It usually shows itself in the first days of extra-uterine life, 
having in all probability begun in foetal life. 

The first marked symptoms are commonly observed from 
the third to the sixth day after birth, when the lower extremities 
are seen to show considerable areas of shining, tense, white 
skin, sometimes tinged with red, or of a dirty-brown or yellowish 
color. The tissues are cedematous, pitting on pressure with 
the finger, while the skin is so much thickened that it cannot 
be pinched into folds between the thumb and finger. Begin- 
ning in the calf, the disease soon extends to the thighs, spreads 
over the abdomen, up the trunk, involves the head and upper 
extremities, and, in fine, after a brief period (three hours to 
three days) invades the entire body. Of course, we can know 
nothing of the subjective symptoms, but the rapid fall in body 



250 DISEASES OF THE SKIN. 

temperature, the frigidity of the affected parts, and the general 
depression of functional activity, point to a serious general 
condition. 

The infant's bodily movements are imperfect and restrained; 
it lies numb and stiff, usually with closed eyes and wrapped in 
lethargic slumber; it declines food, partly on account of mental 
hebetude and partly because of the difficulty of making ' the 
movements of the mouth necessary to nursing. The heart is 
weak, and the pulse is rapid and sometimes almost imperceptible. 
The respirations are irregular and shallow, with occasional 
rales. The patient occasionally utters a complaining w T hine. 
The urine and stools are diminished in quantity. 

The symptoms mentioned usually increase in severity with 
continually falling bodily temperature and increasing weakness, 
until death ends the scene at the end of from four to ten days. 

Sclerema neonatorum is almost invariably fatal, though 
recovery has been noted in a few cases where the disease was not 
extensive. The cause of the disease seems to lie in an extensive 
implication of the blood-vessels. Atelectasis of the lungj, con- 
genital disease of the heart, or other constitutional anomalies, 
have been brought forward as explanatory of the origin of the 
disease. Surroundings and pre-natal conditions of an unfavor- 
able hygienic character — want, privation, etc. — appear to have 
some influence in the causation of the disease. 

Anatomical examination show T s deep involvement of all strata 
of the cutaneous envelope. The widespread infiltration of the 
subcutaneous tissues allows the easy separation of these layers 
from the deeper layers of muscles and the fasciae. On section, 
a yellowish- white, serous fluid, mostly composed of oil globules, 
exudes. Of the internal organs, the lungs and kidneys are 
usually hyperaemic, while the brain and the serous membranes 
are usually cedematous. The brief duration of the affection, 
however, usually allows only the earlier stages of these changes 
to be observed. 

The treatment of sclerema neonatorum is of a roborant and 
restorative nature, and should be undertaken at the earliest 



CEDEMA NEONATORUM. 25 1 

possible moment. Rubbing with hot blankets, etc., and the 
internal administration of restoratives may be employed. 

(EDEMA NEONATORUM. 

(Edema of new-born infants was formerly confounded with 
sclerema, but Parrot has shown that the affections are distinct. 
The disease is generally observed at or within a day or two of 
birth, and not unfrequently in infants born before term. The 
oedema is usually observed upon the calves, posterior portion 
of the thighs, the hands, and the genital organs. The affected 
parts are pale and pit upon pressure. 

Usually this is the extent of the disease, but at times it is 
more severe, the skin becomes livid, and a firm, hard oedema 
may invade the entire body and limbs. Respiration becomes 
difficult and the patient succumbs with suffocation and coma, 
or with some pulmonary complication. 

In lighter cases, tending to a favorable termination, the 
oedema gradually disappears and recovery takes place after 
some days. 

The therapeutic indications are: i. To render the action of 
the heart more vigorous. Hygiene, good food, a small quantity 
of some stimulant, particularly wine, may be employed. 2. To 
favor the dispersion of the effused fluid by re-estabhshing the 
functions of the skin. Friction, massage with warm flannel 
or the warm hand, aided by warm oil, spirits of camphor, etc. 
Friction and malaxation in the direction of the venous current 
is advisable. The vapor of benzoin is sometimes employed. 
3. Warmth. The infant should be placed in a "couveuse" or 
"incubator," or given hot baths, wrapped in hot flannels, etc. 

ELEPHANTIASIS. 

Under the name of elephantiasis arabum, or pachy derma, a 
morbid condition of the skin is designated, which is characterized 
by hypertrophy of the derma and of the subcutaneous cellular 



252 



DISEASES OF THE SKIN. 




tissue limited to certain regions of the body, and the result of re- 
peated attacks of inflammation of the capillaries and lymphatics. 
Elephantiasis occurs under two different forms: (i) the 
elephantiasis of tropical countries, which is due to the presence 

in the economy of the filaria sanguinis 
hominis, and (2) the elephantiasis occur- 
ring in temperate climates and resulting 
from various morbid conditions, most of 
which are unknown or but little under- 
stood. 

The affection usually begins by an at- 
tack like erysipelas, with lymphangitis, 
pain, and fever, followed by slight en- 
largement of the part. Similar attacks 
subsequently occur from time to time, 
the limb or region involved being slightly 
increased in size upon each occasion. At 
the end of a year or more, after a num- 
ber of these attacks have taken place, 
the part is usually found to have increased considerably in size, 
to be chronically swollen, cedematous, and hard. In the limbs, 
the leg particularly, not only will the entire member be found 
enlarged, but the skin itself decidedly hypertrophied, as shown 
by the prominent papillae, fissures, and more or less discoloration 
and pigmentation. A verrucous condition of the surface is also 
very common as shown in the illustrations. The process usually 
goes on until very considerable deformity results. The appear- 
ance of the disease varies in one part or another of the body. 
The commonest seat of disease is in the leg, one limb alone being 
generally attacked. The genitalia are next in point of frequency 
attacked. Other regions are more rarely assailed. 

The amount of pain attending the disease varies; it is sometimes 
severe during the inflammatory attacks, while at other times and 
in other cases no pain is felt. The increased weight of the part, as 
in the case of the scrotum or leg, may interfere with locomotion. 

* Jas. R. Wood's case, Photog. Review of Med. and Surg., vol. ii, p. 37. 



Fig. 37. — Elephantiasis.' 



ELEPHANTIASIS. 253 

Elephantiasis is found in all parts of the world, but is far 
commoner in tropical regions, where it seems to be endemic. 

Lymph scrotum is a form of elephantiasis closely allied to 
chyluria. 

Elephantiasis telangiectodes, also known as "Xaevoid elephan- 
tiasis," is a hypertrophic development said to have a con- 
genital origin and to be due to overnutrition resulting from the 
underlying increase of the vascular supply. 

Acromegaly is a hypertrophic condition allied in its external, 
clinical appearances to elephantiasis. It will be found more 
fully described in works on nervous diseases, as the nerve symp- 
toms predominate. 

Manson has shown that the mosquito is a probable factor in 
the causation of some cases of elephantiasis, particularly in trop- 
ical countries. Poor food, unhygienic living and similar con- 
dition are contributing factors. Elephantiasis sometimes oc- 
curs in connection with leprosy but there is no relation between the 
two diseases. It is not contagious nor hereditary. When occur- 
ring in several members in one family this is rather because the 
patients have been surrounded by the same conditions. 

The pathological changes in elephantiasis are the result of 
lymphatic obstruction and this, in the case of the tropic forms, 
is the result of the invasion of the filaria, while the non-parasitic 
cases such as originate in our country are the result of repeated 
attacks of streptogenous inflammation. 

The seat of the disease change is for the most part in the 
subcutaneous tissue, and the bulk of the enlargement is made 
up of hypertrophic connective tissue. In the verrucous cases 
there is also papillary hypertrophy. After prolonged dura- 
tion of the disease the underlying muscles may undergo atrophy 
and fatty degeneration and the bones may show uniform or 
irregular enlargement. 

The treatment of elephantiasis may be medicinal or surgical. 
During an inflammatory attack, rest, with local sedatives, 
are called for. Boric acid in saturated solution, or ichthyol 
may be applied; in fact, the treatment appropriate to erysipelas 



254 



DISEASES OF THE SKIN. 



is also proper in this stage of the disease. After the pain and 
heat have subsided, the part attacked is to be encased in a closely- 
fitting bandage, alone or in connection with other remedies. 
Methodical compression, is a very important and, up to a certain 
point, the most advantageous treatment which can be applied. 




Fig. 38. — Elephantiasis wilh warty growths. (Courtesy of Dr. Roland G. Curtin.) 



At first the bandage should be applied so as to produce a gentle 
but firm and even pressure, the amount of pressure being grad- 
ually increased from day to day. Thus the oedema is gradually 
reduced, a certain amount of absorption follows, and the venous 
and lymphatic systems regain tone. Strips of adhesive or India- 



ELEPHANTIASIS. 255 

rubber plaster may be used in some cases. Later, Martin's 
rubber bandage may be applied, the limb being first covered 
with a thin layer of cotton batting. Esmarch's bandage has 
been used, but I can see very little advantage in its employment, 
and the loss of tone caused by the sudden emptying of the swollen 
vessels makes it unlikely that a healing contraction will take 
place. More probably the flaccid vessels would rapidly enlarge 
again when the pressure was removed. Some such treatment 
as this, with rest, is the most appropriate, and should be perse- 
vered in as long as it seems to do good. The rest should include 
repose in a horizontal position, and should, if possible, be continu- 
ous. If the leg is the part attacked, it may be bound to a wire 
anterior splint, such as is used in the treatment of fractures, 
and then, if this is suspended on a frame over the bed, considerable 
freedom of movement for sitting up, using the bed-pan, changing 
the sheets, etc., can be attained without disturbing the dressing. 

When eczema, with or without ulceration, is present, some 
approved local remedies may be used simultaneously with the 
bandaging, etc. One of the best forms of dressing for an eczem- 
atous elephantiasis is that of salicylic paste with the double 
muslin bandage, applied wet, as described under eczema rub- 
rum of the leg. 

There comes a time, however, when this form of compression 
ceases to be of benefit, and then the question arises, what further 
can be done to bring. the parts to' a normal condition? When 
the affection is of long standing and a considerable degree of 
fibrous hypertrophy is present, it must be confessed that the 
chance of entire restoration is poor. We know of no medica- 
ment or application which will cause the absorption of fibrous 
tissue on such a large scale. When, however, the effusion is 
slight, or at least when the solid deposit in the tissues is recent, 
massage will often do much toward causing its absorption. 
This plan of treatment also has the advantage that it may be 
employed upon the face, the genitals, etc., where the bandaging 
processes above described would not be available. There is 
no question but that the means of treatment at our disposal 



256 DISEASES OF THE SKIN. 

in elephantiasis of these parts are scanty enough in any case. 
Electricity, in the form of galvanism, has been employed by 
Mann in one case successfully. A zinc-carbon battery of sixteen 
cells was used, and the negative pole, a metal plate, was placed 
on the sole of the foot, while a moistened sponge, attached to the 
positive pole, was brushed across the surface of the limb.* 
Internally, quinine may be given during the febrile exacerbations, 
with a view of abating the fever. Iodide of potassium has also 
been recommended. Sulphide of calcium has recently been 
employed in lymph scrotum with marked success. It is supposed 
to kill the filariae which may be present in the blood or lymph 
channels, and in any case is well worth a trial. The dose is three 
to six grains (0.20-0.40) daily, in divided doses. Change of climate 
is sometimes of great importance. In cases where the disease 
has been contracted in a tropical climate, if the person seeks a 
more temperate region before the hypertrophic condition is far 
advanced, the attacks of fever often cease, and much may be 
hoped regarding recovery. On the other hand, if he remains 
in a tropical climate, repeated exacerbations of fever occur, 
each followed by a progressive advance in the hypertrophic 
process, and recovery is almost impossible. Ligation of the 
femoral artery has been practiced in a number of cases of elephan- 
tiasis of the leg. When the scrotum is attacked, an operation 
with the knife is the best treatment. 

The prognosis of elephantiasis, once fully developed, is unfavor- 
able as regards entire cure. Much may be done, however, in 
the earlier stages of the disease to arrest its progress. Great 
deformity attends the disease. Elephantiasis scarcely ever term- 
inates fatally, though it is said a fatal result may follow an in- 
flammatory attack in rare cases. 

* Helf rich {Deutsche Med. Zeitung, November 7, 1887), recommends in severe 
uncomplicated cases the excision of strips of skin after elastic compression, and 
followed by elevation of the limb and massage. The excision must go through 
as much skin as can be pinched up into a fold. With antiseptic precautions the 
wound heals by first intention. The after-treatment consists in development of 
the muscles by electricity and massage by tapotement. Massage by stroking is to 
be avoided as tending to develop the subcutaneous tissues. Bandaging should 
be continuous. 



DERMATOLYSIS. 

DERMATOLYSIS. 



257 



Dertnatolysis is a rare anomaly of the skin, consisting in a 
more or less circumscribed hypertrophy of the cutaneous and 
subcutaneous structures, characterized by softness and looseness 
of the skin, and a tendency to hang in folds. It is a rare and 




Fig. 39. — Dermatolysis. {After Marcacci.)* 

very striking affection, and may occur over various parts of the 
body, sometimes developing to an enormous size. The " elastic 
skin" men who exhibit themselves in various parts of the country, 



Annates de Derm, et de Syph, 1880, p. 132. 



17 



^ 



DISEASES OF THE SKIN. 



present a striking instance of an anomaly closely allied to dermat- 
olysis. Here, however, a remarkable looseness and elasticity 
of the connective tissue is the chief characteristic. The affection 




Fig. 40. — Dermatolysis. (After Marcacci.) 



is closely allied to elephantiasis. Microscopic examination of 
such cases shows the derma to be transformed into a myxomatous 
mass deprived of the fibrous fasciae which in the normal skin 
limit the excessive elongation of the elastic fibres. The treat- 
ment of the circumscribed form of the disease is removal by the 
knife, or galvano-cautery when this is practicable. 



ATROPHIA CUTIS. 



2 59 



CLASS V. ATROPHIES. 
ATROPHIA CUTIS. 

There are several forms of cutaneous atrophy, some of which 
seem to occur " idiopathically " and without obvious cause, while 
others are the result of some general disorder or of some injury 
to the nerves. In the "glossy skin" of writers upon nervous 
diseases, the extremities, especially the fingers, become pinkish 
or reddish, smooth, shining, and glossy, as though varnished. 
The lesions resemble chilblains in appearance. The affection is 




Fig. 41. — Atrophy of Skin (" Geromorphism Cutanee")-* 

accompanied by burning pain, and follows intractable neuralgia, 
wounds, and other lesions of the nerve trunks. 

General idiopathic atrophy of the skin is a very rare condi- 
tion, in which the skin becomes dark and discolored in patches, 
and swollen, then contracts, becomes of an olive color, and seems 



* Cas d'une atropine idiopathique de la Peau. 
Derm, et de Syph., 1886, p. 505. 



A. Pospelow. Annates de 



260 DISEASES OF THE SKIN. 

too small for the body. The sensibility of the skin is deadened 
and the movements of the body are effected with difficulty. 

Under the name Geromorphism cutanee Charcot describes a 
form of congenital atrophy of the skin producing a curious 
senile aspect. Millard reports a case where transverse striae 
were disposed symmetrically on the anterior and external sur- 
face of the thighs a little below the trochanters subsequent 
to a severe attack of typhoid fever. The patient showed an 
abnormal rapidity of growth in height during this period. 

Atrophia Maculosa et Striata. Another form of atrophy of 
the skin is that known as "atrophic lines and spots." This form 
of atrophy may also be "idiopathic" or symptomatic. In the 
first case it comes without apparent cause, the patient's attention 
often being attracted to the lesions only by accident, and after 
they have existed for some time. The lines {stria atrophica) 
are usually half a centimeter to a centimeter in diameter, and 
three to ten centimeters in length; the spots {macula atrophica) 
are roundish or ovalish, and from a pin-head to a pea- or finger- 
nail size. Both lesions present a smooth, glistening, s^ar-like 
appearance, are perceptibly thinned to the touch, slightly de- 
pressed or grooved, and show a peculiar mother-of-pearl lustre. 
The lines are usually found in numbers running parallel to one 
another, and in an oblique direction. The spots are generally 
isolated. They may occur on any part of the body, but are 
usually found on the buttocks, hips, and on the thighs, upon 
both extensor and flexor surfaces. They run a slow course, 
and give rise to no inconvenience. Their origin is obscure; 
they are sometimes found in connection with morphcea. 

Symptomatic lines and spots of an atrophic character are 
those formed by stretching of the connective tissue bundles, 
as seen on the skin of the abdomen in pregnancy, etc. Occa- 
sionally this form of atrophy may follow severe diseases, as 
typhoid fever. 

Hemiatrophia Facialis. Unilateral facial atrophy is a trophic 
disease of the skin marked by a gradual withering of the tissues, 
affecting one side of the face and involving at first the cutaneous 



ATROPHIA CUTIS. 261 

and subcutaneous tissues, and later the deeper tissues and 
bones. The affection begins as a circumscribed whitish, yellow- 
ish, or brownish discoloration of the skin, accompanied by rapid 
thinning. The discolored patch then sinks in, as a result of 
the atrophy of the subcutaneous tissues, and finally the thinned 
parchment-like skin lies directly upon the bone, without, how- 
ever, becoming adherent to it. The various appendages of 
the skin take part in the affection. The hairs turn white and 
sometimes fall out, the sebaceous secretion is perceptibly dimin- 
ished, while the secretion of sweat is at times increased. 

The appearances described are commonly at first and most 
markedly manifested in the sub-orbital or the lower maxillary 
region, but the chin, forehead, or temple may show the trophic 
depression. The disease may begin at various points simul- 
taneously. In addition to involvement of the external tissues 
atrophy of the tongue and soft palate may occur. Hemiatrophia 
facialis runs a rapid progress at first, and later remains at a 
standstill for long periods, to take up fresh activity some time 
afterward. 

Hereditary influence has not been proved. Women are more 
frequently attacked than men. The affection shows itselfbefore 
the thirtieth year, and usually between the tenth and fifteenth 
year. Of two cases, which have come under my observation, 
one was a boy, the other a young man of twenty, who, however, 
had had the affection some years. 

The causes of the disease are not accurately known, and there 
is much diversity of opinion on the subject. By some the disease is 
considered to be due to some injury or disease of the lymphatics, 
by others due to some direct influence exerted on the trophic fibres 
of the trifacial or other nerves. Another theory is that the per- 
ipheral nerves are at fault, while some French writers conceive, 
the disease to depend upon a primary atrophy of the fatty layers 
beneath the skin. Facial hemiatrophy has in several cases been 
observed to follow measles or scarlatina. One case is on record 
where the disease was bilateral, and another where the shoulder 
and wrist were involved as well as the face. 



262 DISEASES OF THE SKIN. 

Hemiatrophia facialis may be mistaken for vitiligo or alopecia 
areata, but close examination will show an actual loss of sub- 
stance which will distinguish it from these milder affections. 

A diagnosis having been made, the affection, for practical 
purposes, passes out of the hands of the dermatologist. Elec- 
tricity forms the most hopeful plan of treatment, but the pros- 
pect of restoration to health is highly unfavorable. 

VITILIGO. 

Vitiligo is an affliction of the skin characterized by the dis- 
appearance or transfer of pigment in the affected areas, and by 
an accumulation of pigment in the immediately surrounding 
portions of skin. It shows itself in the form of one or more, 
usually sharply defined, rounded, ovalish or irregular-shaped, 
variously-sized and distributed, smooth, whitish spots, around 
the borders of which the surrounding skin shows an increase of 
pigment. The number of spots is usually not numerous, although 
larger areas or even the entire surface may be involved in rare 
cases; they are smooth and on a level with the surrounding skin, 
and save for the discoloration cannot be distinguished from it. 
The texture of the affected skin is, indeed, normal, except that 
the amount of pigment has diminished, a diminution which 
extends to the hairs growing on it, which usually turn white. 
The disease is popularly known as "piebald skin," and when 
occurring in the negro, has sometimes given rise to the notion 
that the skin was turning white, like that of a Caucasian. In 
many cases when vitiligo affects the scalp or other hairy parts, 
the hairs over the affected area turn white, and occasionally fall 
out. The disease is striking and disfiguring. Vitiligo sometimes 
disappears spontaneously after years, but treatment has little 
effect. The occurrence of vitiligo seems to depend in some way 
upon faulty innervation. Leloir has observed parenchymatous 
neuritis in the nerve fibrils distributed to the affected patches. 

Clinically, vitiligo is often found in connection with nervous 
disorders, peripheral and central. It is said occasionally to 
be the precursor of tabes. Arsenic is the only remedy which, 



ALBINISMUS. 263 

in my experience, has had a good effect, when used for months. 
Electricity, hydrotherapy, and all means of improving the general 
nutrition should be resorted to. 

Feulard reports the cure in a young girl of vitiligo, accom- 
panied with alopecia areata (between which and vitiligo there 
seems at times to be some connection), by applications of acetic 
acid, followed by tincture of cantharides and the occasional use 
of solutions of bichloride of mercury, say four grains to the 
ounce of alcohol and water. 

The disease is sometimes mistaken for morphcea, macular leprosy, 
and chloasma. A reference to the description of these diseases 
will show wherein they differ. 

ALBINISMUS. 

The condition known as albinism, consists in a congenital absence of the 
normal pigment. It may be partial or general. In the latter case the sub- 
jects are known as albinos. Here the skin is of a milky-white or pinkish 
color, the hair white, yellowish-white or red, and even the iris and choroid 
of the eye are more or less deprived of pigment. It is said that in the negro 
the eyes are not affected, and cases are on record where the color of the 
affected patches has returned. This affection is to be carefully distinguished 
from vitiligo (q. v.). 

AINHUM. 

Ainhum is a disease peculiar to the African race, who first gave it 
this name, which signifies " to saw," and is characterized by a slow, 
progressive, fatty degeneration, generally with increase in volume of the 
toes, especially the smallest, resulting from a linear strangulation. The af- 
fection begins by a not quite semi-circular furrow in the digito -plantar fold, 
occupying the internal and inferior portion of the root of the small toe, with- 
out anv marked inflammation, pain or ulceration which may attract the 
attention of the individual affected. Gradually the furrow becomes deeper, 
and sometimes slightly ulcerated, and extends itself to the upper (dorsal) 
and external surface of the toe, thus forming, at last, a circular groove; 
while the anterior part of the toe — that is, that which is in front of the 
groove — becomes swollen to twice or three times its natural size and loses its 
shape, becoming oval or almost globular. The epidermis becomes rough; 
the nail is said not to become particularly changed, but it is turned outward 
by the rotation of the toe on its axis, which always takes place when the 
pedicle by which the toe remains attached to the foot becomes very thin, and 
the anterior part of the toe interferes with progression. Spontaneous ampu- 



264 DISEASES OF THE SKIN. 

tation sometimes takes place. The affected parts preserve their normal 
sensibility. 

The progress of the affection is very slow, the time elapsing between the 
formation of the original furrow and the more or less perfect completion of 
spontaneous amputation having been, in some instances, ten years or more. 
When the little toe of one foot has been affected some time, that of the other 
foot becomes usually likewise diseased. After both the small toes are re- 
moved, neither any other toe, nor any of the fingers, nor any other part of 
the body becomes affected. (In rare cases the little fingers have been found 
affected.) 

Brazil, the West Indies, and the West Coast of Africa are the commonest 
localities of the disease, but within the last few years cases have been re- 
ported from the southern United States. In the early stages free transverse 
incision of the constricting band may arrest the disease. The only treatment, 
after strangulation has been effected, is the early removal of the useless and 
cumbersome member. 

PERFORATING ULCER OF THE FOOT. 

Perforating ulcer of the foot is a tropho-neurotic atrophy of the skin, 
affecting usually the sole, although the palm may be affected, and which, 
beginning as a callous formation, develops into an indolent and usually pain- 
less sinus leading down through the deeper tissues to the bone. 

The- most elaborate study of the disease has been made by Savory and 
Butlin.* It begins with the formation of a localized callosity or epidermal 
thickening, sometimes essentially the nature of a corn, most usually situated 
over the articulation of the metatarsal bone with the phalanx of the first or 
last toe, the regions which are subject to more or less pressure. Suppura- 
tion and necrosis take place beneath the callosity which is thrown off, dis- 
playing a small, deep, perforating ulcer or sinus, the opening of which is 
surrounded by granulations. Walking is usually painful. In typical cases 
other tropho-neurotic changes are observed. There are probably ulcers from 
pressure which are mistaken for true perforating ulcer. The disease usually 
occurs in connection with tabes and other nervous disorders. 

Treatment of true perforating ulcer is unsatisfactory. Even amputation 
has been followed by the development of an ulcer in the stump. Fortunately 
the pseudo-tropho-neurotic perforating ulcer is that most frequently met. 
Here the horny callosity is to be soaked in hot water or covered with a 
salicylic acid plaster until it softens and then pared off with a knife or dug 
away with a sharp spoon. The ulcer is then to be stimulated by the ap- 
plication of nitrate of silver and dressed with aristoi or europhen. The 
prognosis in pseudo-neurotic perforating ulcer is good. 

* London Medico-Chir. Soc. Transactions, vol. lxii, 1879, p. 373, with plates, etc.; 
also, Gasquel, These de Paris, July 1890. 



KELOID. 265 



CLASS VI. NEW GROWTHS. 

Cicatrix, or ordinary scar may be included under new growths. There are 
two varieties, the elevated or hypertrophic and the depressed scar, the scar 
formation developing only sufficiently to skin over or cover the preceding 
depressed wound or ulcer. The scar, even when hypertrophic, shows no 
tendency to invade the surrounding healthy tissue as does keloid. To form 
a scar the damage to the skin must involve the corium; destruction which 
extends only to the corium, although removing the whole epidermis, includ- 
ing the rete, does not leave a scar, being replaced. 

The scar is composed of interlacing bundles of connective tissue with ab- 
sence of glandular structures, lymphatics, hair follicles, hairs and furrows. 
Xerves are rarely present. 

Scars tend to grow less with time, although in the case of children they 
grow with the general growth. The treatment of scars is generally surgical. 
Multiple scarifying, ''cross hatching," is sometimes of use. Acne and small- 
pox scars are said to have been improved in appearance by the use of the 
X-ray. 

KELOID. 

Keloid is a fibro-cellular new growth of the corium, character- 
ized by one or more irregularly-shaped, variously-sized, elevated, 
smooth, firm, somewhat elastic, pale red, cicatriciform lesions. 

The disease usually begins as a small, pea-sized nodule, 
increases slowly in size, and commonly assumes an ovalish, 
elongated, or crab-claw-shaped form, or may occur in streaks 
or lines. The lesion varies greatly in shape, and may be quite 
small or as large as the palm. The outline is well defined, 
and the surface contour rounded and highest in the center. 
Taken between the fingers it has a firm, dense, slightly elastic feel. 
Its surface is smooth, shining, and generally devoid of hair, and 
its color reddish or pinkish. The lesion is usually single, though 
several may exist simultaneously. It is more common over the 
sternum, but it is also met with on the mammae, neck, ears, 
arms, and elsewhere. It is sometimes painful, especially on 



266 DISEASES OF THE SKIN. 

pressure, and occasionally, but rarely, it itches. Now and then 
acute inflammatory symptoms may arise in a keloidal tumor, giv- 
ing it a malignant appearance. These usually disappear in turn 
spontaneously. The course of the disease may be rapid or slow; 
having attained a certain growth it is apt to be stationary, and may 
remain a lifetime, though in most cases it ultimately disappears. 

Keloid may originate spontaneously or in cicatrices. The 
two varieties run into each other. Cicatricial keloid often orig- 
inates in the most insignificant scars. Bites of leeches, erosions, 
or pin-scratches are enough in individuals predisposed to the 
disease. Lehonneur {These de Paris, 1856) saw a case where 
the pressure of a shirt button was sufficient to give rise to keloid. 
Besnier has seen multiple keloid follow non-parasitic sycosis, 
and I have observed the same in several cases. Acne, es- 
pecially of the variety known as acne indurata, of the back 
and chest, is often followed by keloid. Psoriasis may be followed 
by keloid (Purdon). Keloid of the lobe of the ear, following 
the piercing for ear-rings or the wearing of ear-rings, is not 
uncommon. Burns by fire, or chemicals, particularly the latter, 
cuts, flogging, tattooing, and wounds of all kinds are not unfre- 
quently followed by this growth. Keloid is also met with in 
syphilitic individuals.* 

The occurrence of spontaneous keloid, at first admitted, 
was for some years doubted by many dermatological au- 
thorities. At present, however, its existence has been proved 
beyond a doubt by the observations of De Amicis (Cong, de 
Dermatol., 1889), Ory (Bull, de la Soc. Anat., 1875), Schwim- 
mer (Ziernsserts Hand-book), Bouzon (These de Paris, 1893). 
Most cases reported were of multiple tumors, from a dozen 
or so in number up to 318 in the case reported by De Amicis. 

In the case, both of spontaneous and cicatricial keloid, some 
constitutional peculiarity seems to be present. Most writers 
consider heredity to play a part in the production of this growth 
but facts in support of this view are wanting, excepting in the 

*R. W. Taylor {Jour. Cut. and Ven. Dis., 1883, p. 308) says that keloid oc- 
curs in one-half of one per cent, in his experience of syphilitic practice. 



KELOID. 267 

cases reported by Hebra. "Scrofula" has also been invoked, 
but without much evidence to support the view of its diathetic 
effect. It is otherwise with syphilis. Bouzon finds that an 
analysis of 75 reported cases of keloid gave 16 or 20 per cent, 
when the patients were syphilitic, a great increase in the propor- 
tion over Taylor's statistics, but both writers consider syphilis 
to be a marked predisposing cause. The negro race is pecul- 
iarly susceptible to keloid. 

Under the microscope the lesions of keloid are seen to be 
made up of a dense, fibrous mass of tissue, whitish in color and 
composed of compact bundles of connective tissue, having their 
seat in the corium, and arranged in a meshwork. In the newer 
lesions fusiform cells and blood-vessels are found in this mesh- 
work and extending beyond the macroscopic limits of the growth. 
The newer keloid lesions look a little like sarcoma under the 
microscope; the older ones like fibroma. 

The symptoms of keloid are so striking that no difficulty 
need be experienced in making a diagnosis. It is most liable 
to be mistaken for simple cicatrix, from which it may be dis- 
tinguished by its color, outline, elevation, and consistence, and, 
frequently, by the presence of pain. Acne keloid (Dermatitis 
Papillaris Capillitii), however, is very liable to be mistaken for 
ordinary keloid. A careful study should be made of all cases 
of keloidal acne occurring on the nape of the neck or about the 
scalp. 

The treatment of keloid is rarely satisfactory. When operated 
upon by the knife or caustic it is apt to return, and frequently 
in an aggravated form. Caustic potash is the best caustic 
to use, but the growth should be touched with great caution 
while it is still making progress, or disappointment may be the 
result. Two forms of treatment have recently been recom- 
mended as successful. One of these consists of repeated scari- 
fications, such as are described under lupus vulgaris. These 
must be perserved in, as at first the keloid surely returns. After 
a while, however, it is said to disappear. Parasiticide remedies 
should be applied simultaneously. Hardaway has used multi- 



268 DISEASES OF THE SKIN. 

pie puncture with the electrolytic needle with success. Marie 
avoids scarification, and uses hypodermic injections of creasote 
dissolved in oil (20 per cent.). The operation is followed by 
pain for some hours and causes suppuration, which results in 
destruction of the growth without relapse. Hypodermic injec- 
tions of morphia are occasionally required to allay the pain. 
Chloroform and anodyne liniments may also be prescribed for 
the same purpose, and I have used the fluid extract of hama- 
melis with benefit. Wilson recommends painting the group 
with a solution containing one drachm of iodide of potassium, 
an ounce of soft soap, and an equal quantity of alcohol, followed 
by the application of lead plaster spread on a piece of soft leather, 
the dressing being kept on a week and then replaced by another. 
The prognosis of keloid is not very favorable. The utmost 
that can be said in any given case is that it may disappear either 
spontaneously or under the use of supposed remedies after a 
time. Perhaps scarification and electrolysis may be more suc- 
cessful than the other forms of treatment. Its course is usually 
progressive, with occasional temporary arrest of development. 
Very often, however, the lesions remain stationary for years. 

DERMATITIS PAPILLARIS CAPILLITII. 

This affection, which partakes of the nature of sycosis, acne, 
and keloid, at once, is usually found upon the back of the neck 
just below the hairy scalp. The initial lesion is a follicular and 
perifollicular inflammation simulating ordinary acne. It is 
accompanied, however, from the beginning by a deep infiltra- 
tion of the derma, which can be perceived by pinching the skin 
between the fingers. 

The hair follicles involved are usually completely destroyed; 
some, however, persist and often appear in the form of a bunch 
of two, three, or more hairs springing from a common opening 
in the center or edge of a keloidal tubercle, and resembling a sort 
of brush. These hairs are thick and twisted, being evidently 
altered from their normal condition. Around each pustule of 



DERMATITIS PAPILLARIS CAPILLITII. 269 

acne a keloidal growth forms, constituting in time a nodulated 
hard tumor over the entire area implicated. The nodules 
vary in shape and elevation, but are mostly somewhat conical 
and about the size of a large indurated acne tubercle. In the 
white races the color of the lesions is a bright red or rose color, 
sometimes showing fine branching capillaries like those observed 
in keloid. About the border of the affected region small acne- 
form pustules or rather folliculitis pustules are seen, which are 
traversed by hairs. 

The lesions have a tendency to group and form by confluence 
large indurated masses, which resemble and, in fact, are often 
taken for keloidal tumors. The seat of the affection is almost 
invariably upon the back of the neck, just below the edge of the 
scalp, where it occupies a broad transverse band about where 
the collar rubs. It may occur, however, elsewhere. Acne 
pustules are usually found at the same time scattered about, 
especially in the region of the moustache and beard. 

Lebou has shown that Dermatitis papillaris capillitii is a 
perifolliculitis of the hair follicles in which the embryonal tissue 
surrounding the follicles, instead of tending to suppuration, 
goes on to the formation of sclerous tissue. 

The disease is extremely rebellious to treatment, and the prog- 
nosis, when the process is fully developed, is unfavorable. All 
sources of irritation should be avoided; a large soft collar should 
be worn, or, better, no collar. In the early stages of the disease 
the acneform pustules should be destroyed as soon as they form. 
They should be opened and tincture of iodine or solutions of 
bichloride of mercury or ichthyol should be applied to the cavity. 
External treatment over the whole surface, including the sur- 
rounding skin, should be continuously employed. Salicylic acid 
rubber plaster on the lesions, with frequent and thorough applic- 
ations of bichloride soap or sapo viridis, should be followed by ap- 
plications of a parasiticidal character, as ichthyol, a saturated 
solution of boric acid in alcohol, etc. Occasional poulticing with 
starch poultices sprinkeld with boric acid will aid the treatment. 
The thermo-cautery may also be used with good effect. 



270 DISEASES OF THE SKIN. 

The knife, which is very frequently called into play in the 
removal of the tumors, is not effective unless immediately fol- 
lowed by cauterization. There is no doubt that the affection 
is infectious and due to the invasion of some parasite not yet 
described. It spreads by auto-inoculation, which is favored 
by the use of the knife in operation. 

MOLLUSCUM CONTAGIOSUM. 

Molluscum contagiosum is a disease of the skin, characterized 
by the appearance of rounded, semi-globular or wart-like pap- 
ules or tubercles, of a whitish or pinkish color, varying in size 
from a pin-head to a pea. The lesion frequently looks like a 
drop of wax upon the skin, or like a pearl-button, flattened on 
top and with a darkish point in the center, representing the aper- 
ture of a follicle. They usually occur on the face, especially 
the eyelids, cheeks, and chin. They are also met with on the 
neck, breast, and genitalia. They increase in size slowly or 
rapidly, and are usually without sign of inflammation, though 
inflammation may exist at times. They eventually terminate 
by disintegration and sloughing of the mass. They give rise to 
no pain, itching, or other inconvenience. The affection is un- 
questionably contagious. 

Molluscum contagisum is not a disease of the sebaceous glands 
as formerly supposed. It is a hyperplasia of the rete or a benign 
epithelioma. Opinions differ as to whether it takes its start 
from the epithelial lining of the hair follicle or in the rete layer 
proper. Although the disease is probably parasitic, the psoro- 
sperm bodies found by some observers do not seem to be the 
true parasites. 

Molluscum contagiosum is liable to be confounded with 
molluscum fibrosum, but the two may be distinguished by their 
anatomical characters. In M. contagiosum the opening of 
the follicle can often be seen as a blackish point at the apex 
of the tumor. The lesions are superficial and rise above the skin. 
They are mostly confined to the face. The tumors of M. fibro- 



MOLLUSCUM CONTAGIOSUM. 



271 



sum do not show the black follicular opening. They are also 
found in great numbers all over the body, and are not confined 
to one or two localities. From warts, which they sometimes 
resemble, the tumors of M. contagiosum must be distinguished 
by a careful comparison of structure. 

Local treatment is alone required. Applications of ointment 




Fig. 42. — Molluscum contagiosum. 



of white precipitate, or sulphur ointment, well rubbed in, will 
sometimes suffice to remove the tumors. If this fails they may 
be opened with a small knife, the contents squeezed out and the 
bottom of the cavity cauterized with nitrate of silver. They 
may also be burned out with mild caustics, but severe measures 



272 DISEASES OF THE SKIN. 

should never be used, because the disease is slight and tends 
to get well spontaneously. Electrolysis has been recommended 
by Rohe and Hardaway. 

MULTIPLE BENIGN CYSTIC EPITHELIOMA. 

This affection, known also as epithelioma adenoides cysti- 
cum and hydradenome eruptij, besides various other designa- 
tions, is characterized by small tubercular or nodular lesions of 
a pinkish, pearly or pale yellowish color; and usually seated about 
the face, upper part of the trunk anteriorly and posteriorly, and 
less frequently on the arms. The lesions begin as black dots or 
minute flat skin-colored papules. They vary from pin-head 
to pea-size, projecting above the surface, and have a shining 
semi-translucent appearance. They are usually rounded, conical, 
or in the larger lesions flat, with a slight central depression. 
At times minute capillaries can be seen in the surrounding skin. 
They usually remain stationary but occasionally may show de- 
generation and ulceration with rolled edge like an epithchoma. 

The disease begins in early adult life. It is an epithelial 
growth, the epithelial cells occurring in masses with occasional 
cysts. In some cases it resembles epithelioma in structure. 

The lesions are to be distinguished from those of molluscum 
contagiosum, hydrocystoma, and colloid miliun. 

The treatment should be removal by the knife or caustic as in 
epithelioma. 

ADENOMA SEBACEUM. 

This affection is characterized by the appearance of small 
tumors which are congenital or appear soon after birth. These 
are pin-head to split-pea sized, rounded, convex, either normal 
skin color or waxy, brownish or reddish. The surface may be 
smooth or rough and is covered with fine blood-vessels. The 
tumors are more or less grouped or bunched at either side of the 
nose or they may be scattered over the whole face or even appear 



LYMPHANGIOMA. 273 

upon the scalp. The skin is apt to be coarse grained with large 
gland openings. 

The disease is a hyperplasia of the sebaceous and probably 
also of the sweat glands. 

In rare cases involution has been noted but the affection when 
once established usually persists. The tumors may be removed 
by the curette, the knife, or electrolysis. 

Adenoma of the Sweat Glands. Most cases described under 
this head are in reality multiple benign cystic epithelioma, but 
it would appear that a few genuine cases have been reported. 
They are among the rarities.* 

LYMPHANGIOMA. 

New growths of the lymphatics of the skin have been described 
in isolated cases by numerous authors, the appearances being 
so different in the various cases that it has been very difficult to 
assemble any considerable number into a single type. Wegner,t 
however, divides the various forms of the disease into (a.) lymph- 
angioma simplex, (b) lymphangioma cystoides and (c) lymphan- 
gioma cavernosum or circumscriptum, {Morris). 

Lymphangioma simplex consists both of dilatation and of 
new growths, it presents the appearance of isolated or grouped, 
circumscribed swellings, compressible and somewhat elastic, 
variously-sized and with somewhat dilated lymphatic channels 
leading into them. The genitalia, lips and mouth are the most 
frequent localities. The surface is covered with transparent 
vesicles in greater or less number which, if ruptured, give exit 
to fluid (milky ?) exudation sometimes lasting a long time. Such 
lymphangiomata when situated on the lips forms one variety of 
macrocheilia and on the tongue macro glossia. 

Cystic lymphangioma is usually congenital in origin, consist- 

* See references in Stelwagon under this head. 

tWegner, Archiv. j. Klin. Chirurg., 1877, vol. xx, p. 641. See also Pospelow, 
Arcliiv. f. Derm, u Syph, 1879, p. 521, and Noyes and Torok, Brit. Jour. Dermatol., 
1890, p. 359 and 1891, p. 8. Numerous other references are given by Stelwagon, 
Dis. Skin, 4th Ed., p. 627, et seq. 
18 



2 74 DISEASES OF THE SKIN. 

ing of large multilocular cysts, most commonly seen on the upper 
part of the neck, in which regions they are often known as hygro- 
mata colli. In this locality they may be very deeply prolonged. 
These tumors belong rather to the domain of surgery. 

Lymphangioma cavernosum or circumscriptum is a limited 
regional or patch eruption connected with the lymphatics, 
characterized by pin-head to small pea-sized, usually somewhat 
deep-seated, often red-dotted, closely crowded vesicles. 

The eruption, which is rare like the other forms of lymphan- 
gioma, consists in groups of variously-sized, thick-walled frog- 
spawn-like, grayish, pinkish or reddish vesicles, the grouped 
aggregation being one to three inches in diameter; warty 
growths and telangiectases are also seen. The eruption 
usually is found on the shoulders, neck and scapular region. 
Though some of the vesicles disappear, the tendency is to grow 
or in cases to appear to shift from one spot to another. The 
disease is usually congenital, though it has been known to develop 
from the border of a scar. 

Authorities differ as to the histology of the disease, but it is 
usually supposed to be a dilatation and new growth of the 
lymphatic capillaries with, in some cases enlargement of neigh- 
boring blood-vessels forming a lymphangiectasis and telangiec- 
tasis combined, from which the tumors develop. 

Lymphangioma tuberosum multiplex is a somewhat similar 
condition, cases of which have been described by Pospelow, 
Roberts, and myself. The affection is of very rare occurrence, 
and is characterized by the appearance of numbers of tumors 
scattered, or in groups, over the general surface of the trunk. 
The lesions vary from small split-pea to hazel-nut size, of a reddish- 
brown or bluish-white color, smooth, rising from the surface, 
and rounding into it. On pressure over the larger lesions, the 
finger sinks deeply into the tissues, as into a bladder filled with 
fluid. They are accompanied, in some cases at least, by numer- 
ous lesions of fibroma molluscum. 

Microscopic examinations show the tumors to be composed of 
connective tissue, traversed by numerous lymphatic dilatations. 



XANTHOMA. 275 

XANTHOMA. 

Xanthoma is a slightly elevated, flattened or somewhat rounded, 
soft, neoplastic growth of a yellowish color, usually seated as 
one, several or more lesions about the eyelids and occasionally 
of more or less general distribution. Two varieties are described, 
xanthoma planum, in which the lesions are flat, and xanthoma 
tuberculatum or tuberosum, when they are nodular. 

The plane variety is usually found upon the eyelids in the 
form of one or several roundish or square, smooth, opaque, yellowish 
patches looking often like a piece of dull chamois skin let into 
the skin. Occasionally they may be darker and even brown 
in color. They may be symmetrical or confined to the upper 
or lower lid of one side, sometimes they are fused into an orbicular 
patch covering the entire lids and extending slightly beyond. 
They give rise to no sensation whatever. This form of xanthoma 
develops very slowly and once fully formed shows no tendency to 
heal although cases are on record where the lesions have spon- 
tanously disappeared.* 

Xanthoma tuberculatum or tuberosum, sometimes called 
xanthoma multiplex, may be found on any part of the body 
except the eyelids. The most common localities are the hands, 
elbows, knees, buttocks and feet. The lesions are rounded and 
from pea-size to considerably larger, even to egg size. They 
occur singly or grouped. In children the affection often occurs 
in numerous and disseminated lesions. Excepting as regards 
outline and grouping they are essentially the same as the lesions 
of xanthoma planum or "palpebrarum" as it used to be called. 

Xanthoma may occur on the mucous membranes, the cornea 
of the eye and possibly elsewhere. 

Jaundice is said to be a not infrequent precursor or accom- 
paniment of xanthoma multiplex. 

Pathologically xanthoma is a benign, connective tissue new 
growth development with concomitant or subsequent partial fatty 
degeneration. The chief changes are in the corium the epi- 

*C. F. Legg, Path. Soc, London Lancet, vol. 2. 1879, p. 617. 



276 DISEASES OF THE SKIN. 

dermis being slightly if at all affected. Large cells filled with 
fat granules and closely aggregated fat-drops, having a defined 
membrane and large, sometimes several or more nuclei are 
found lying between the bundles of connective tissue, consti- 
tuting the so-called " xanthoma cells." 

Xanthoma does not tend to spontaneous cure. The lesions 
may be removed by incision, the curette and when small by 
caustics or electrolysis. The X-rays have been used in some 
cases to advantage.* 

XANTHOMA DIABETICORUM. 

Xanthoma diabeticorum is a rare affection observed in dia- 
betic individuals, consisting of scattered, sometimes grouped 
and aggregated, somewhat inflammatory, papular or nodular 
elevations, with, usually, in most lesions, the basal portion red- 
dish and the apex of a yellowish or yellowish-white color, and 
generally accompanied by slight subjective sensations of itch- 
ing or pricking. 

The eruption may come on gradually or it may be abundant 
from the start. The lesions are somewhat firm or hard, pin- 
head to small pea-sized, rounded or conic, rather sharply defined 
papules, usually discrete, though sometimes aggregated or in 
patches. The lesions are usually of a dull reddish color at first 
and later show more or less of a yellow tinge resembling xan- 
thoma planum. Though occurring anywhere on the body the 
favorite seat of the eruption is on the buttocks, forearms, elbows, 
knees and back. 

There is almost always sugar in the urine in typical cases 
and the amount of the eruption is said to vary with the degree of 
the diabetes. In all the cases I have seen, immediate relief 
or entire disappearance of the eruption followed the successful 
treatment of the diabetes. 

Microscopically the lesions resemble those of the other forms 

*See Schwimmer, Ziemssen's Hand-book of Diseases of the Skin, p. 577; also, 
Pollitzer, New York Med. Jour., 1899, vol. ii., p. 73. A histological Study. 



N^VUS VASCULOSUS. 277 

of xanthoma excepting that the inflammatory element is more 
marked and the connective tissue growth less pronounced. 

The treatment is that of diabetes. Locally carbolic and other 
anti-pruritic washes may be employed. 

COLLOID DEGENERATION OF THE SKIN. 

{Colloid Milium.) 

This extremely rare affection is characterized by the appearance in the skin 
of numerous small tumors — rounded, flat, or raised — the size of a pin's head 
to a split pea, of a pale or lemon color, bright, shining, and translucent. 
They look like vesicles, but when pricked are found to be firm, or to exude 
a little blood and transparent gelatinous fluid. The favorite sites are the 
forehead, about the orbits, the nose and the cheeks. The lesions have also 
been observed on the cornea and the septum nasi. The process is a colloid 
degeneration of the connective tissue of the corium. The treatment is re- 
moval by scraping with the sharp spoon, when this is practicable. 

NjEVUS VASCULOSUS. 

Naevus vasculosus {angioma, mother's mark, port-wine mark, 
birth mark, etc.) is a congenital new growth and hypertrophy 
of the vascular tissues of the corium and subcutaneous tissues. 

Blood vascular growths occur in three forms, ncevus vasculosus, 
telangiectasis, and angioma cavernosum. 

Ncevus vasculosus includes those vascular anomalies of the 
skin which are either visible at birth or very soon after. It 
occurs in the form of one, or sometimes several, spots, from the 
size of a small pin-head to that of the palm of the hand, or larger 
tracts. While these are usually level with the skin, the smaller 
ones are occasionally found raised like small red tumors. The 
color of the lesions varies greatly. Usually it is a bright red, 
but at times it has a deep port-wine tint. In some cases the 
color is like a stain or an erythematous blush. At other times 
tortuous blood-vessels may be seen coursing over the surface. 
Pressure by the finger causes a momentary pallor. The epider- 
mis over the lesions remains unchanged. On superficial inspec- 
tion the lesions seem sharply defined, but on closer examination 



278 DISEASES OF THE SKIN. 

the edge of the vascular area is seen to fade gradually into the 
surrounding skin. 

Naevus vasculosus has little tendency to grow when once 
developed. Occasionally, especially in the case of infants, 
phagedena or gangrene will suddenly occur in these patches 
without appreciable cause (probably in consequence of the occur- 
rence of thrombus), and the entire growth will slough away, 
leaving a scar exactly delineating the area of the former naevus. 

As regards the cause of naevus, the explanation given by 
Virchow, namely, superfluous vascular formations in those por- 
tions of the embryo at which junction of the various parts takes 
place, seems most plausible. A small quantity of matter left 
over, squeezed out between the joints as it were, like superflu- 
ous building material, forms these naevi and the similar growths 
of lymphatics, hair, pigment, etc. 

Naevus vasculosus simplex is most frequently met with about 
the head, and next to this upon the trunk, and then the extrem- 
ities. Among 333 cases observed by Weinlechner, 243 were 
found upon the head. Of these 200 were in the face, of which 
54 were frontal, 35 palpebral, 32 nasal, 30 labial, and 26 buccal. 
Of 20 cases of naevus of the face which I have seen, 12 were in 
females and 8 were in males. As regards position, 14 were on 
the right side, 4 on the left side, and 2 appeared to be symmetrical. 

The treatment of vascular naevus, aside from the radical 
surgical measure of bodily removal by the knife or ligature, 
has one principal underlying it, namely, that of obliterating 
the blood-vessels by pressure, inducing coagulation, or by exciting 
enough inflammatory action in the growth to obliterate the caliber 
of the vessels composing it. This may be accomplished in any 
one of a number of ways. Minute naevi no larger than the head 
of a pin may be destroyed by puncture with a red-hot needle, 
or with a needle charged with nitric or glacial acetic acid, or by 
electrolysis, with the aid of one or more needles connected with 
the positive pole of a four- to ten-cell combination of a constant 
current battery. When the growth is a little larger, from the 
size of a split pea to that of a ten-cent piece, it may be treated 



N^VUS VASCULOSUS. 279 

by caustic applications. Of these, sodium ethylate is one of 
the most efficient. It rarely causes severe pain, and may be 
applied on the end of a glass rod. Other caustics are nitric 
acid and glacial acetic acid, which are available in the larger 
as in the smaller-sized naevi. Solution of caustic potash is 
also occasionally used, although this is a remedy of dubious value, 
since, to get it strong enough for a proper effect on the tissues, 
we must make it so powerful as to run the risk of too rapid action 
and consequent hemorrhage. Injections of tincture of the 
chloride of iron, with tincture of cantharides, carbolic acid, 
and the like, into the substance of the growth, have been recom- 
mended, but these methods are not without danger, when the 
growth has not been first isolated, and fatal cases of embolism 
have been reported as following the use of the iron solution. 
Vaccination has long been practiced in suitable cases. The 
virus must be pricked in with needles at a suitable number of 
contiguous points simultaneously. Linear scarification, as used 
in telangiectasis and rosacea, may occasionally be employed. 
The galvano-cautery and Paquelin's cautery have also been 
used. Recently the X-ray has been employed and I have found 
it of great value in extensive superficial cases. 

The prognosis of naevus vascularis is usually favorable. The 
growth gives rise to little or no sensation, rarely increases in 
size, except sometimes at the second dentition, and sometimes 
decreases or disappears spontaneously, especially at puberty. 
Occasionally, however, the smaller and prominent growths under- 
go malignant change, and this, as well as their unsightly appear- 
ance, should be considered by the physician who may be called 
upon for an opinion as to the advisability of treatment. 

Angioma cavernosum consists of a dense framework of new- 
formed connective tissue enclosing loculi or chambers of varying 
capacity, containing blood, and not only communicating with 
each other, but with the larger vessels in the vicinity. They 
are said to be rarely congenital, but are acquired soon after 
birth. Sometimes they originate from a naevus or superficial 
telangiectasis. Often when fully formed they are distinctly 



280 DISEASES OF THE SKIN. 

encapsulated. The baggy purplish masses or tumors, filled 
with contorted, vein-like channels, sometimes met with on the 
faces of adults, are cavernous angiomata. They belong rather 
to the field of the surgeon than to that of the dermatologist. 

TELANGIECTASIS. 

Telangiectases are new growths consisting of blood-vessels, 
and in this respect are similar to naevi. They differ form the 
latter, however, in being acquired, and not congenital. They 
are commonly first observed in adult life and occasionally 
multiply with advancing years. They occur in localized and 
in diffuse forms. The diffuse form is excessively rare. I have 
observed one case. 

The localized forms of telangiectasis are characterized by 
the occurrence of minute, flat or slightly elevated, pin-head to 
pea-sized maculae; diffuse patches; linear ramifications of individ- 
ual vessels or contorted congeries of a plexus of the latter, usually 
pinkish or violaceous in color. The lesions are non-inflammatory 
and painless, and occur single or in small numbers, chiefly upon 
the face, but also upon the neck, back of the hands, etc. They 
may occur in the neighborhood of various skin diseases, partic- 
ularly in leprosy, keloid, lupus, scleroderma, etc., cicatrices, 
and sometimes upon the surface of tumors. In angiokeratoma 
angioma pigmentosum et atrophicum, rosacea, etc., they form 
the chief element. The treatment is the same as that of naevus 
vasculosus. 

ANGIOMA SERPIGINOSUM. 

This is an exceedingly rare disease beginning in early life, insidious and 
slow, and characterized by the appearance of minute, firmly-seated, pin- 
point to pin-head sized, elevated, bright red to dull red, or purplish points 
or papules. The lesions increase in size and then involution begins in the 
center, while the lesion extends in the periphery so that an annular circulate, 
or serpiginous configuration is assumed. Infective satellites form beyond 
the periphery and go through the same evolution. The center is not cica- 
tricial but only slightly discolored. The process seems to be of an angiosar- 
comatous character. It is to be distinguished from lupus vulgaris, q. v. 



FIBROMA. 



28] 



FIBROMA. 

Fibroma, also called moJhiscum fibrosum, is a chronic hyper- 
trophic affection of the skin, characterized according to the 
variety of the affection by a single or a few pendulous tumors, 




Fig. 43. — Fibroma, diffuse form. (After Recklinghausen.) 



or by numerous sessile or pendulous growths of the cuta- 
neous connective tissue. Though it is possible that these two 
varieties may run into each other, the generalized variety very 



252 DISEASES OF THE SKIN. 

often showing one or several tumors of large size, and the cir- 
cumscribed tumor being occasionally accompanied by a num- 
ber of small lesions, yet it will be convenient to consider them 
separately. 

The generalized form of the disease is characterized by the 
presence of cutaneous tumors, from a dozen or more to thousands 
in number, sessile or prominent, roundish in outline, soft, indo- 
lent, and generally of small size, though occasional exceptions 
occur. The lesions are found on all parts of the surface, even 
upon the palms or soles, but are usually most numerous upon 
the head and trunk, where they are sometimes so closely set as 
to be confluent. They occur somewhat less frequently upon 
the limbs, diminishing as the extremities are approached. The 
skin covering the genitals is occasionally, though rarely, affected, 
In some cases, where a post-mortem examination has been made, 
some of the internal organs have been found to display these 
tumors, and in several cases they have been observed in numbers 
upon the nerves. 

The lesions vary in size from that of a pin-head to a hazd-nut, 
and are found occasionally as large as a hen's egg, but rarely 
larger. The smaller ones may be felt in the skin but rarely rise 
above the surface, while the larger ones are more prominent 
and tend to become pedunculated and pendulous. The seat 
of the lesions is in the derma, and they move with it. Their 
color is that of the normal skin or slightly pinkish; occasionally 
they are covered with a fine vascular network, giving a violaceous 
tint. On some lesions, especially those upon the back, the ori- 
fice of a dilated sebaceous duct can be seen, from which a plug 
of sebum (comedo) may be squeezed. The sebaceous glands, 
however, are in no way essentially connected with the growth; 
nor are the hairs, but the latter occasionally fall out, probably 
from pressure. 

The tumors are of various consistency, but they are always 
more or less soft and flaccid, excepting in the case of the larger 
ones, which are occasionally distended and firm, with a smooth, 
glistening surface as if the tumor were cedematous. Alongside 



FIBROMA. 



283 



of such tumors may be seen others which have a flaccid, empty 
feeling, like a scrotum without its testicles or a raisin deprived 
of its seeds. A curious point is that, although the tumor can be 
rolled between the fingers, firm pressure reveals a firmer central 
core of tissue vaguely defined to the touch. 




Fig. 44. — Fibroma. 



Generalized fibroma is an indolent disease, and patients rarely 
come under the notice of the physician excepting for some inter- 
current affection. While the tumors usually seem perfectly 
stationary, yet now and then a case is observed in which one 
or several of the lesions seem to increase in size and may become 



284 DISEASES OF THE SKIN. 

enormous. The period at which this change takes place varies 
in different cases. It may occur at puberty, or in the female 
during gestation if the tumor be seated upon the labia. The 
growth thus distinguished becomes pendulous, while preserving 
its rounded form, or takes the form of a dewlap, approaching to 
the kindred formation known as dermatolysis, pachydermatocele, 
cutis pendula, etc. (See Dermatolysis.) 

Circumscribed fibroma commonly occurs in the form of one, 
two, or rarely three tumors (which in the latter case are situated 
alongside of one another) of variable, but always considerable size, 
which is the greater according to the size of the tumor. The size in 
some cases reported has been enormous. In one case an enor- 
mous fold of skin sprang from the ear, which was greatly elongated, 
and from the back of the head, covering the neck, chest, and 
abdomen, fell in voluminous folds like a mass of intestine. The 
patient when seated was obliged to carry the mass in her lap. 

The localities from which these single tumors spring are the 
temple, upper eyelid, the nucha, behind the ear and at the level 
of the last cervical vertebra, the chest below the breast to the 
hip, and, chiefly, the labia majora. In one case the growth 
sprang from the sole of the foot. The skin covering these lesions 
is normal or slightly pigmented, smooth, or rough and rugous. 
In consistence they are like a mammary gland to the touch. 

Circumscribed fibroma is indolent and only calls for re- 
lief when the tumor is so large as to inconvenience the pa- 
tient, when an operation may be required. Degenerative 
changes of an inflammatory or malignant character sometimes 
occur in the tumors of fibroma molluscum, particularly of the 
circumscribed variety. 

The etiology of fibroma is obscure. Hebra has asserted that 
the disease occurs in persons of stunted mental and physical 
growth, and this is the experience of many writers, which has 
also been mine in the cases I have observed. It is more common 
among women than among men. Fibroma is a rare disease; 
only 86 cases were reported in the 112,775 cases of the American 
statistics. 



NEUROMA. 285 

It is a curious fact, and one worthy of note, that in all cases 
of fibroma which have been examined post-mortem, new growths 
similar to those on the skin have been found upon the main trunks 
of the nerves. It has been suggested that fibromata of the skin 
are originally neuro-fibromata, the nerves being at first present 
and then disappearing as the tumor grows and the connective 
tissue becomes prominent. 

The diagnosis of fibroma rarely presents any difficulty. The 
number and distribution of the lesions, the unchanged character 
of the skin covering the tumors, the variety in size and shape of 
the latter, and the pendulous character of the larger tumors, 
are all highly characteristic. From molluscum contagiosum the 
tumors are to be distinguished, by not having any depression 
or aperture upon their summits. In rare cases where this exists 
a comedo can be squeezed out of the opening. They are, more- 
over, situated in the skin, which is normal over them, whereas 
the lesions of M. contagiosum are nearer the surface of the skin, 
which is tightly stretched over them. The tumors of fibroma 
are distinguished from those of lipoma by the fact that the 
latter are soft and lobulated in structure. The diagnosis 
between fibroma and other hypertrophic growths of the skin is 
rendered difficult because our ideas regarding the line to be 
drawn between fibroma and such affections as dermatolysis, 
pachydermatocele, and elephantiasis, are indistinct. 

The prognosis of fibroma is favorable excepting for possibil- 
ity of malignant degeneration, which, though extremely unusual 
must be considered. 

The treatment is limited to the removal of unsightly or dis- 
comforting tumors by the knife or the galvano-cautery. 

NEUROMA. 

Neuroma is a rare affection, characterized by the presence of variously- 
sized and shaped nerve growths, having their seat primarily in the true skin. 
The lesions are visible to the eye as split-pea-sized tubercles, scattered, or 
aggregated in large numbers over the affected locality. The lesions are of a 
rose or pink color, smooth and firm, and the intervening skin normal. 
Pain, of a paroxysmal character, and extremely severe, is the chief symp- 



286 DISEASES OF THE SKIN. 

toms. Movement of the affected part, a draught of cold air, or even mental 
worry and excitement are often sufficient to cause pain and even agony. 

A microscopic examination of the tumors in the few cases observed has 
shown them to be composed of medullated nerve fibres and connective tissue 
in varying proportions, and in one case of smooth muscular fibres also. 
They were, in fact, actually fibromata, at least in the case of the older 
lesions. (See Fibroma.) 

The affection must be distinguished from painful subcutaneous tubercle, 
a not uncommon affection. Here the lesion is usually single, and is not sit- 
uated in the skin, but in the subcutaneous tissue. 

The only treatment of neuroma cutis is the excision of a portion of the 
nerve trunk leading to the affected area. This has given entire relief in one 
case, while in another case the same operation failed entirely. 

MYOMA. 

Myomata, or dermatomyomata, are small tumors occurring either single 
or multiple. One variety, the more common, is solitary or grouped in a 
single locality. The lesions are cherry to apple sized, and may be sessile or 
pedunculated. Their usual seat is upon the breasts and genitalia in both 
men and women. 

They are contractile, vascular, of slow growth, and usually indolent, 
although at times they are found to cause much pain. The tumors are usu- 
ally composed of smooth muscular fibres, but may contain considerable 
fibrous tissue, in which case they are known as fibromyomata. Sometimes 
the vascular element predominates, and at other times the lymphatic, so 
that, at times, the exact character of a given tumor may be very doubtful. 

Simple or generalized myomata constitute an exceedingly rare affection. 
They are characterized by minute tumors the size of a lentil, more or less, 
of slow development, roundish or oval, of a pale rose or a deep red color, 
according to their size, and disseminated here and there over the trunk or 
limbs. Their peculiarity is that they are tender and painful, often to a high 
degree, the pain often occurring in paroxysms of extreme intensity. They 
are composed of unstriated muscular tissue, The treatment is ablation by 
knife, caustic, or electrolysis. 

RHINOSCLEROMA. 

Rhinoscleroma is a chronic neoplastic affection, starting in the mucosa of 
the nose, particularly of the alae and septum, and extending gradually to 
the cartilages and skin of the nose and surrounding parts. In a few cases 
the posterior part of the soft palate and neighboring organs, as the larynx 
and trachea, are the starting point. As the growth enlarges, the shape of 



TUBERCULOSIS CUTIS. 287 

the nose is gradually altered, becoming broader and flatter, and the organ 
feels hard and rigid to the touch like ivory. The lumen of the nose becomes 
occluded, the surrounding parts partake of the growth and become quite 
disfigured. The color is normal or reddish, smooth and is traversed by 
small blood-vessels. 

The direct cause of the disease is supposed to be the bacillus rhinoscler- 
omatis. Histologically the process is considered of a granulomatous charac- 
ter. Rhinoscleroma is highly rare in this country and thus far has only been 
met with among foreigners. 

Removal by the kaife is perhaps the best treatment, but the tumors are 
apt to recur. It does not threaten life at any stage. 

TUBERCULOSIS CUTIS. 

Tuberculosis of the skin includes all those affections which 
are caused by the tubercle bacillus. Considerable confusion 
at present exists regarding the exact relationship obtaining 
between some of these diseases, but the attempt will be made to 
include the most important ones recognized by authoritative 
writers. We may arrange the tuberculodermata under the fol- 
lowing heads: (i) Accidental inoculations, (2) tuberculous 
ulcers, (3) scrofuloderma, (4) lupus vulgaris. 



ACCIDENTAL INOCULATIONS. 

Under the head of accidental inoculated tuberculosis are in- 
cluded the various forms of anatomical, or dissection tubercle, 
or wart. The anatomical tubercle is usually inoculated in dis- 
sections or in operations on tuberculosis patients. The hand 
is the common seat of such inoculation and particularly the 
thumb and forefinger, a circumstance which is explained by the 
frequent contact with various objects which may bear the con- 
tagion. Cases have been observed in which tuberculosis of this 
variety has been inoculated upon the forearm by contact with a 
tuberculous patient. Other cases where the face or other parts 
have been wounded by utensils belonging to tuberculosis patients 
have been reported. 



265 DISEASES OF THE SKIN. 

Anatomical tubercle usually shows itself first by the appear- 
ance of a small red papule, in the center of which is seen a white 
point which softens and ulcerates, exuding a thin sero-pus. It 
then becomes covered with a yellow crust; not infrequently a 
series of similar papules form around the qriginal one, ordin- 
arily coalescing with it to constitute a larger lesion. 

Occasionally a lesion is accompanied on its appearance by a 
more intense inflammatory action resembling an abscess or felon, 
and results in an ulcer covered with a grayish crust. 

When completely developed the anatomical tubercle is made 
up of a warty infiltration of the skin of a livid red color, the sur- 
face of which is covered with hard, horny masses divided in 
numerous segments; the shape of the lesion is irregular, the 
development extremely slow, and the lesions may grow to the 
size of a quarter of a dollar by coalescence of similar elements. 

At this period the anatomical tubercle seems to remain for 
some time in statu quo; occasionally, however, new lesions appear 
in the neighborhood. Microscopic examination shows very 
much the same appearance as that presented in some forms of 
lupus. 

Under the name of tuberculosis verrucosa, is described a form 
of tuberculosis cutis, which is somewhat similar to the anatom- 
ical tubercle. According to the authors who have described this 
form of tuberculosis cutis, however, this form of tuberculosis 
does not necessarily occur in connection with inoculation from 
without. It may be observed in persons who are already suffer- 
ing with the symptoms of general tuberculosis. It is much more 
active in its nature, tending to spread more rapidly, and is often 
accompanied by secondary infection, as shown by lymphangitis 
and adenitis, and subsequently visceral tuberculosis. The 
diagnosis of these forms of tuberculosis of the skin is sometimes 
difficult, but the peripheral hyperaemic border, the miliary ulcer- 
ation around the lesion or at the bottom of the fissure, and the 
tendency to cicatrization in the center in older cases are quite 
characteristic. The diseases with which tuberculosis verru- 
cosum is most likely to be confounded are the ordinary wart, 



TUBERCULOUS ULCERS. 2SO. 

simple papilloma, benign vegetations, papillary epithelioma, pap- 
illomatous naevus, some forms of lichen planus and of syphilo- 
derma. Some years ago I met with a case where the initial 
lesion of syphilis produced accidentally by an operating knife 
resembled very closely the anatomical tubercle. This lesion 
occurred on the tip of the index finger of the right hand. I was 
at first convinced that it was an ordinary wart and treated it 
as such. Somewhat later I came to the conclusion that it was an 
anatomical tubercle, but was extremely surprised when my pa- 
tient appeared with enlargement of the axillary glands and 
generalized erythematous eruption unquestionably syphilitic in 
character. Perhaps the diagnostic mark in this case should 
have been the locality, as tubercle is much more apt to occur on 
the back of the finger around the nail. 

TUBERCULOUS ULCERS. 

The tuberculous ulcer is usually found seated upon the muco- 
cutaneous surfaces of the buccal and anal regions but may 
occasionally be found elsewhere. It is generally single but 
occasionally several ulcers have been observed in the same 
neighborhood or separated in various regions of the body. The 
ulcer rarely exceeds one to two centimeters in diameter, it is 
usually circular or oval and occasionally polycyclic in outline 
resembling in this respect the lesions of herpes. The edges 
are sharply defined, looking as if punched out or even slightly 
undermined. The ulcer secretes a small quantity of sero-puru- 
lent fluid and is rarely covered by a crust ; it is granular, mammil- 
lated and covered with small reddish points intermingled with 
reddish-gray projections. The tuberculous ulcer is usually 
painless. 

SCROFULODERMA. 

That form of tuberculosis of the skin to which the term " scrof- 
uloderma" has been most generally applied is the tuberculous 
gumma of the skin. This sometimes begins in one or more 
19 



290 DISEASES OF THE SKIN. 

of the superficial lympathic glands, especially under the jaw, 
about the neck and clavicular region. The glands become 
enlarged and the process extends to the skin overlying them, 
which becomes red and infiltrated. Finally, a cold abscess 
forms, and is discharged through the skin, and an ulcer of slow 
progress, with undermined violaceous border results. 

At other times the process begins in the external skin where 
it is known as the "scrofulous gumma" on account of its re- 
semblance to syphilitic gumma. The most superficial of these 
gummata begin as a small infiltration or node in the skin, of a 
livid red color. Increasing in size, slowly at first, and later 
more rapidly, the lesion sometimes extends in one or more di- 
rections, involving the entire skin and softening at one or more 
points to form small ulcers, with burrowing sinuses extending 
from one to another. The discharge from these ulcers is usu- 
ally sero-purulent or sanious, and occasionally bloody, and the 
skin may be undermined by numerous communicating galleries. 
Occasionally the disease takes on a diffuse, infiltrating form, 
spreading in an irregular patch over the skin, involving its entire 
surface and giving rise to serpiginous, shallow ulcers. 

The scrofulous ulcer never shows any disposition to heal. 
It may look as if it were on the very verge of cicatrization, but 
it does not actually scar over, or, if it does, a week or two later 
the cicatrix opens in one place while forming in another. 

In addition to the localities above mentioned, this form of 
scrofuloderma may occur over the cap of the shoulder, in the 
groin, and elsewhere. It is generally accompanied by other 
signs of the scrofulous condition, by old scars, etc. 

In children this form of tuberculous disease often shows 
itself in the form of funmculoid lesions which break down rapidly, 
form abscesses and when numerous may lead to a fatal result. 

Another form of disease which was first described by Duhring 
under the name of the small pustular scrofuloderm shows itself 
in the form of small, hard, scattered, flat papules, with a raised 
violaceous area. The lesions may occur upon any part of the 
body, but are usually met with upon the forearms, legs, and 



SCROFULODERMA. 29 1 

face. At first, they look like the small pustular syphiloderm, 
but crust over after some weeks and the crust, dropping off later, 
leaves a depressed pit-like cavity of a size to admit the head 
of a pin. Finally the lesion disappears, leaving a punched-out 
scar like that of small-pox. The course of the disease is extremely 
slow. New lesions form while the old ones are cicatrizing and 
while the affection does not give rise to any pain or other annoy- 
ing sensation, it is very rebellious to treatment. 

A type described by Duhring as the large, flat, pustular scrof- 
uloderm appears in the form of one or more pin-head to small 
split-pea sized indurations which soon become pustular and 
enlarge peripherally, forming a fairly large, flat, often irregularly- 
shaped, yellowish or brownish-yellow, flat, thin, crusted pustule, 
with an areola of a dull red or violaceous color. The crusting 
is slow, beginning in the center, and quite scanty, unlike the large, 
flat, pustular, syphiloderm where the crust is thick and extends over 
the whole lesion with an abundant secretion of pus underneath. 
When the crust of the scrofuloderm is removed a superficial, 
irregular, edged, granular looking scrofulous ulcer, with uneven 
base covered with thin purulent secretion, is seen. The ulcers 
may heal in the center and spread peripherally. Their course 
is slow. They leave a soft superficial scar. 

Treatment of Tuberculosis of the Skin. The important point 
in the treatment of tuberculosis of the skin is to destroy 
the center of the disease, which may, if left alone, infect the 
entire system. Where the lesions are superficial, easily gotten 
at, and in a position where caustics or other destructive agents 
can be used, the suppression of the lesion is not difficult, but 
occasionally the superficial skin lesions are accompanied by inter- 
nal foci of disease which cannot be reached by any caustic or 
other local measures. The internal treatment of tuberculosis 
of the skin is sometimes neglected. I think that we cannot go 
wrong in administering cod-liver oil in considerable doses, either 
pure or made up as the pharmacists supply this remedy in the 
present day. The French writers suggest six to eight table- 
spoonfuls in 24 hours. This is a much larger dose than most 



292 DISEASES OF THE SKIN. 

of our patients in this country are able to bear, but my impres- 
sion is that the larger the quantity of the oil which can be taken 
and digested the more benefit may be expected. Where cod- 
liver oil is not easily digested I have sometimes found very good 
benefit from the aid of bread and butter. It should be urged 
upon patients as a medical prescription. When taken in very 
large quantities the system is supplied with very digestible, fatty 
matter, and I have sometimes observed most excellent effects from 
this remedy. After all, it is only a question of some easily diges- 
tible fat to be introduced into the economy. In addition to 
cod-liver oil the syrup of the iodide of iron in very considerable 
doses is often found useful. I, myself, have observed some cases 
of lupus improve very much under iodide of potassium. Of 
course, the general hygienic treatment of tuberculosis now so 
well known should be employed and it must be remembered 
that cases of tuberculosis of the skin are apt to develop tuber- 
cle in other organs so that general prophylaxis is practiced. 

LUPUS VULGARIS. 

Lupus Vulgaris. Lupus vulgaris is a very chronic, new cell 
growth, depending upon infection with the bacillus tuberculosis, 
characterized by variously-sized and shaped, reddish or brown- 
ish patches, consisting of papules, tubercles, or flat infiltrations, 
usually terminating in ulceration and cicatrices. 

The disease varies in appearance in different cases, and also 
according to the locality attacked and the stage of its develop- 
ment. It usually begins by the formation of small, yellowish- 
red or brown points under the skin, which increase in size, coal- 
esce, and form irregularly-shaped, roundish or serpiginous, 
ill-defined patches of various size. The points referred to enlarge 
until they form papules, and finally tubercles. It is at this 
stage that the disease usually comes under notice. The lesions 
are of all sizes, from pin's head to split pea, are brownish- or 
yellowish- red in color, and are covered with a thin layer of imper- 
fectly-formed epidermis. They are firm or soft, and are pain- 
less. At this stage of development the disease may retrograde 



LUPUS VULGARIS. 



293 



and terminate in absorption of the lesions, leaving a thin, des- 
quamative, cicatricial tissue, or it may go on to ulceration and 
complete destruction of the infiltrated skin, resulting in much 
disfigurement. In its earlier stages lupus vulgaris is rarely 
attended by any subjective symptoms, but later there is some- 
times pain. The commonest seat of the disease is about the 




Fig. 45. — Lupus vulgaris. 



face, especially the nose, cheeks, and ears. It frequently attacks 
the extremities, especially the fingers, where it may result in 
serious deformity. The limbs and trunk may also be involved. 
Lupus vulgaris is a destructive disease, often resulting in seri- 
ous disfigurement. It spares none of the external tissues, and 
may invade the mouth, cartilages of the nose, ear, larynx, and 
even the eve. 



294 DISEASES OF THE SKIN. 

The disease usually originates in childhood. It is never 
congenital. It is rarely, if ever, hereditary. It is much com- 
moner on the continent of Europe than in Great Britain, and is 
rare among natives of the United States. 

The diagnosis of lupus vulgaris from syphilis, the disease with 
which it is most likely to be confounded, is chiefly to be made 
by the history of the case in question. In addition, the ulcers 
of lupus are comparatively superficial; those of syphilis ordinar- 
ily deep, and often having an excavated appearance. The ulcer 
of lupus is commonly less extensive than that of syphilis. In 
lupus there arc, as a rule, a number of points of ulceration 
which tend to become confluent ; whereas, the ulcers of syphilis 
usually remain distinct. The border of the syphilitic ulcer is 
sharply defined; that of lupus is not apt to be so. The secretion 
of the syphilitic ulcer is apt to be copious and offensive ; that of 
lupus is scanty and inodorous. The crusts of lupus are thin and 
brownish; those of syphilis are bulky and frequently have a 
greenish tinge. Lupus is slow in its course; syphilis is rapid. 
A syphilitic ulcer may form in five or six weeks, while it may 
take as many years for the lupus disease to give rise to so much 
destruction. The scar of lupus is distorted, hard, shrunken, 
and yellowish. That of syphilis is whitish, smooth, thin, often 
surprisingly small, considering the destructive process which has 
gone before. A history of other syphilitic symptoms is some- 
times, though by no means always, to be obtained in syphilitic 
ulcer, and too much stress must not be laid on the absence of 
this. 

Lupus may be confounded with epithelioma. Though the 
diseases may occur together, yet such occurrence is rare. The 
localization of epithelioma, with its usually painful character, 
and the circumscribed induration of the lesion, will usually 
serve for the diagnosis. The ulceration of epithelioma generally 
starts from one point and spreads peripherally, while the ulcer- 
ation of lupus usually begins at many points within the patch. 
Epithelioma very seldom occurs in the young; lupus begins in 
childhood. 



LUPUS VULGARIS. 295 

Lupus vulgaris is to be distinguished from L. erythematosus 
by the occurrence of ulceration, which never takes place in the 
latter. The patches in L. erythematosus are superficial, uni- 
formly reddish in color, and are at times covered with adherent, 
grayish scales. They are, moreover, circumscribed, and are 
without papules or tubercles. The sebaceous glands and fol- 
licles are generally markedly involved in L. erythematosus; in 
L. vulgar's they remain unaffected. 

Acne rosacea at times bears some resemblance to lupus vul- 
garis, but may readily be distinguished by its dilated vessels, 
color, the presence of acne pustules, its history, and its course. 

The treatment of lupus vulgaris is chiefly local, though con- 
stitutional remedies are also to be employed. It appears to be 
somewhat more amenable to internal treatment in this country 
than abroad. It is, however, one of the most obstinate of all 
cutaneous diseases. Hygienic treatment is of great import- 
ance. Cod-liver oil is the most efficient internal remedy, and, next 
to this, iodide of potassium. It may be given with the oil, as 
may also iodine and phosphorus. Internal 'remedies should 
usually be well tried before external applications are made, as 
they alone sometimes suffice to obtain a cure. The external 
remedies used in the treatment of lupus vulgaris are of a me- 
chanical nature, or comprise various caustics. They should 
be selected with a view to the extent, locality, and character 
of the lesions in any given case. In the earlier stages stimula- 
ting applications may be employed, with a view to bring about 
absorption. Equal parts of tincture of iodine and glycerine, 
painted over the part, mercurial plaster, tar, and ointment 
of the red iodide of mercury may be used for this purpose. I 
must confess, however, that in my hands these milder remedies 
have usually failed of success, and I have always, sooner or later, 
had recourse to more severe measures before a cure could be 
obtained. Of true caustics, potash, nitrate of silver, arsenic, 
carbolic acid, acetate of zinc, chloride of zinc, and pyrogallic 
acid may be mentioned. The first and last of these I believe 
to be most efficient. 



296 DISEASES OF THE SKIN. 

Caustic potassa should be used when thorough and extensive 
destruction of tissue is desired. A stick of the caustic should 
be wrapped in a bit of rag, with only the point protruding, and 
this should be bored into all the disease-foci, which will be 
found to break down easily. It should be remembered that 
the effect of this caustic goes somewhat beyond the point touched. 
Dilute acetic acid or vinegar should always be kept at hand to 
limit and check the spread of the caustic and to neutralize it. 
The pain is severe for the moment, but ceases on the applica- 
tion of the acetic acid or vinegar. Nitrate of silver is efficient in 
some cases, and is said not to leave scars. Papules and tubercles 
may be destroyed by boring into them with the solid stick, while 
patches are most successfully treated by the saturated solution 
repeatedly applied with the charpie brush.. Nitrate of silver 
is one of the best caustics to use in operations on lupus about 
the face, but it does not penetrate deeply. 

The following formula of Unna's is also recommended: 

1$. Hydrarg. bichlor., gr. iij (0.2) 

Acid, carbolic, gr. xij (o 8) 

Alcoholis, f 5j. (4- ) M. 

A small, sharpened stick is dipped into this solution, and bored 
into each little lupus deposit. The pain is brief. 

Pyrogallic acid, in the form of ointment, one drachm (4.) to the 
ounce (32.), applied thickly spread upon cloths, and renewed twice 
daily, is painless and efficient in many cases. It selects the 
diseased tissue and acts but little, or not at all, on the healthy. 
Chloride of zinc is used according to the following formula: 

1^. Zinci chloridi, 

Antimonii terchloridi, aa, 3ij l (8-) 

Acidi hydrochlorici, q. s. M.. 

Enough acid is added to dissolve the chloride of zinc, and 
the mixture rubbed up in a mortar with enough powdered liquor- 
ice to make a paste. This is spread upon a cloth and applied 
while moist. It is a powerful caustic, very painful, and eats 
through healthy and diseased tissue alike. I have never found 
occasion to use it. 



LUPUS VULGARIS. 



297 



Ethylate of sodium is an excellent application, and being less 
painful than some other caustics, may be preferred in small 
operations not demanding an anaesthetic. 

It should be applied on a glass rod, the parts dried so far as 
possible, and no water should be allowed to touch the parts while 
the ethylate of sodium is being applied. 




Fig. 46. — Dermal curettes. 



Erasion, or scraping by means of the curette or scraping spoon, 
is useful in many cases, and is a plan of treatment I can highly 
recommend from experience. The instruments are cup-shaped, 
of steel, with sharp edges, and fastened by a short shank to a 
convenient handle. In size, they vary from a split pea to half 
the size of a teaspoon. 

The part to be operated upon is first frozen 
by means of a hand-ball atomizer, charged with 
ether or rhigolene, or by the application of a 
gauze bag filled with powdered ice and salt, and 
the diseased tissue is scraped or dug out. If any 
of the diseased tissue is left, a recurrence of the 
lupus must be looked for; the operation, there- 
fore, must be thorough. Small nodules remain- 
ing may be removed by the use of the dental burs Fig. 47.— Dental 
and excavator here pictured, as suggested by Dr. 
George H. Fox, of New York. Scraping may often be appropri- 
ately supplemented by the application of caustics, as pyrogallic 
acid, caustic potassa, or even the actual or galvano-cautery. One 
of the best forms of treatment is by linear scarification. Squire 
has devised a multiple-bladed knife, by which this operation, 
over large surfaces, is much facilitated. 




298 DISEASES OF THE SKIN. 

The scarifier pictured below is one which I have devised, em- 
ploying the principle suggested by Squire, with an arrangement of 
the blades suggested by Pick. In my instrument, five blades, 
shaped like those commonly employed for gum lancets, are ar- 
ranged parallel to one another, the central one being fixed in a 
small ivory handle, and the others being removable so as to fa- 
cilitate their cleansing. The handle of the instrument is to be 




GEHRIG & SON 



=^» 



Fig. 48. — Multiple scarifier. Van Harlingen's modification. 

held like a pen, and a series of parallel cuts are to be made, going 
as deeply as is considered necessary. Cross cuts are then made, 
and the cross hatching is continued until in severe cases, the 
whole surface is hashed up. After excision or scarification a 
caustic should be applied, with antiseptic dressing to follow. 
The operation may have to be repeated, but in the end a clean, 
healthy scar is the result. 

Besnier considers that lupus vulgaris is often transmitted by 



Fig. 49. — Holder for galvano-cautery knives. About half-size. 

the "bloody operations," as they are called, such as excision, 
scarification with knives, erasion with curettes, etc. He, there- 
fore, recommends the employment of the electro-cautery.* 

Besnier employs a number of electro- cautery knives of various 
shapes, with the view to reach all the various sized and shaped 
deposits of lupous tissue in the skin. Many of these I habitually 
employ. My favorite knives are the flat-bladed knife and the 
point. 

* The healing power may be derived from a Fleming cautery battery (see Fig. 
51) or from a storage battery like that used in the portable X-ray apparatus. 



LUPUS VULGARIS. 



299 



When only a small space is to be covered, most patients can 
endure the pain, which is but momentary. When a considerable 
area is to be operated upon, however, ether must be admin- 
istered. 

The knives are to be heated to a dull cherry- red, and as most 
operations are about the face, some care must be exercised to 
avoid ignition of the ether when this anaesthetic is employed, 
and even more when rhigolene spray is used. 

Of late years the Finsen and the Rontgen or X-ray treatments 



Fig. 50. — Besnier's galvano-cautery knives. 

have superseded other forms of local treatment in hospitals 
and large cities where these methods can be employed. As 
regards the Finsen method this depends upon the bactericidal 
effects of concentrated chemical rays, using the arc light and 
controlling or preventing the action of the heat rays. The 
technique of this method is so complicated and its use so restricted 
that it seems unnecessary to describe it at length in this work 
and reference may be made to special papers on the subject.* 

* See in particular Malcom Morris and Dore, The Light Treatment in Lupus 
and other Diseases of the Skin, Practitioner, April, 1903. 



3°° 



DISEASES OF THE SKIN. 






The use of the X-ray in the treatment of lupus vulgaris is 
now an accepted procedure and being much more readily obtain- 
able in this country than the Finsen light may be resorted to in 
certain cases, especially where the disease is extensive, to great 
advantage. It does not always agree with the skin and in a 
certain number of cases excites violent inflammation without 
ameliorating the disease, but where it agrees the effect of the 
X-ray is peculiarly rapid and satisfactory. 

Sometimes a small dose is sufficient but usually X-ray dermatitis 

to the second degree, vesi- 
culation or serous exuda- 
tion must be produced be- 
fore an impression is made 
upon the disease. Caution, 
however, should be em- 
ployed in this as in the 
milder skin diseases in 
order that an excessive ef- 
fect may not be produced. 
Stelwagon suggests that 
"the first exposure should 
be given with a tube of low 
or medium vacuum at ten 
inches, distance for five 
minutes, duration and at 
intervals of three or four 
days. After a period of ten 
days to two weeks, if no 
susceptibility has been shown, the distance can be gradually 
reduced to three or four inches and the time lengthened to ten 
or fifteen minutes and the exposures made at more frequent 
intervals." "In those instances where moderate reaction has 
been purposely provoked and kept up, after a few weeks, 
treatment should be discontinued until this subsides, and in 
some cases improvement sets in and continues. The method 




Fig. 51. — Cautery battery. 



LUPUS VULGARIS. 



3OI 



should again be resumed as soon as improvement begins to 
flag."* 

The prognosis of lupus vulgaris will depend upon the form 
of the disease, its duration, the age of the patient, and the extent 
of surface involved. The disease, in any case, is very stubburn, 




Fig. 52. — Portable X-ray aparatus as made by Queen & Co., Phila. 

and runs a chronic course. If it be confined to one patch or 
region, a more favorable termination can be looked for. The 
disease usually results in marked scarring and deformity. 

The pathology of cutaneous tuberculosis is a complicated and as yet not 
very clearly understood subject. So far as the anatomy of the lesions is con- 

* The X-ray apparatus given in Fig. 52 shows the minimum required in the phys- 
ician's office or by the patient's bedside. This can be added to as the taste or 
requirements of the operator may demand to an indefinite extent. As regards 
technique reference may be made to the works of Pusey and Caldwell and of 
Allen on Radiotherapy. 



302 DISEASES OF THE SKIN. 

cerned this has been thoroughly worked out. (See Bowen, The Pathology 
of Cutaneous Tuberculosis, Boston Med. and Surg. Jour., Nov. 12, 1891, p. 
516.) But theories as to the introduction of the bacillus and the possibility 
of morbid action from toxins have not been uniform nor conclusive. Stel- 
wagon and Hyde and Montgomery may be consulted in their more elaborate 
treatises by those desirous of knowing the prevalent speculations on this 
subject. 

LUPUS ERYTHEMATOSUS. 

Lupus erythematosus is a chronic, mildly or moderately 
inflammatory, small-celled superficial new growth formation, 
characterized by one, several, or more, circumscribed, variously- 
sized, usually oval or rounded, discrete or confluent, pinkish to 
dark red patches, covered slightly and more or less irregularly 
with adherent grayish or yellowish scales, and seated most 
commonly upon the face, less frequently upon the scalp also, 
and exceptionally upon other parts. 

The disease usually begins in the form of one or more round- 
ish, pin-head to small pea-sized, erythematous patches, which 
enlarge upon their periphery, and often coalesce to form larger, 
irregularly-shaped patches. After a time the patches increase 
in thickness and show more infiltration, and when fully developed 
there may be a number of patches, varying in size fram a split 
pea to a silver dollar, or the palm of the hand, having usually 
a distinct and clear-cut marginal outline. In color they are 
reddish or violaceous, and are sometimes covered with fine or 
coarse, grayish or yellowish, remarkably adherent scales, at 
times scanty, at other times forming sebaceous-looking crusts, 
like those found in eczema seborrhceicum of the face. In 
localities where the sebaceous glands are large, as upon the nose 
and adjacent parts, the crusts are firmly attached to the open- 
ings of the sebaceous glands, which are often plugged up with 
sebum or denuded and patulous. In other cases, the eruption 
does not seem to involve the sebaceous glands in particular, 
but seems purely erythema-like in form and appearance. 
The patch spreads on its margin, which is usually higher 
than the center, the latter being commonly paler, and often 



LUPUS ERYTHEMATOSUS. 303 

showing atrophic depression. After a variable time the 
patch attains a certain size, and may remain stationary. 
There is never any moisture or discharge in connection with 
the disease. Sometimes it seems to spread by the occurrence 
from time to time of erysipelas-like attacks, after the cessation 
of which the area of permanent disease will be seen to have 
increased and new circles to have formed. 

Lupus erythematosus is usually found upon the face, one or 
both cheeks, below the eyes, and the bridge of the nose, being the 
commonest seat of the affection. Often both of these localities 
are attacked by the disease, which forms the rude figure of a 
butterfly with outstretched wings. The muco-cutaneous and 
mucous surface of the lips, the ears, scalp, back, chest and 
other parts of the body may be attacked. Lupus erythematosus 
is remarkable for its chronicity and may persist through life. It 
tends to increase, from time to time, by repeated attacks. Ultim- 
ately, the process is apt to end in the formation of a superficial 
cicatricial tissue. 

The subjective symptoms vary in different cases, depending 
somewhat upon the activity of the disease. At times there is 
much burning and itching, while in other cases there may be 
no subjective symptoms. 

Females are more liable to it than males, and light- than dark- 
haired persons, and it occurs notably on those who are subject 
to disorders of the sebaceous glands, sometimes, indeed, appear- 
ing to originate in a patch of localized seborrhcea. 

The views of various observers regarding the etiology and 
pathology of L. erythematosus vary considerably. There is little 
doubt in my mind that the disease is in some way related to 
tuberculosis although the tubercle bacillus is not found in the 
lesions. 

Robinson * concludes that L. erythematosus is a chronic in- 
flammatory disease of the cutis with special histological char- 
acters, as shown in the changes in the blood-vessels — new blood- 
vessels in the affected area, lymph-vessels and lymph-channels, 

*Trans. Am. Derm. Assn. 1808. 



304 DISEASES OF THE SKIN. 

and the new formation of an adenoid tissue — reticular tissue — 
the presence of mononuclear and absence of polyneuclear cells 
in the cell infiltration ; and these changes must depend upon the 
presence of a poison generated in loco. In other words lupus 
erythematosus is a local infective process — a granuloma. 

When fully developed, the typical patch of lupus erythem- 
atosus offers such a striking picture, with its reddish or viola- 
ceous color, its sharply circumscribed outline, its infiltrated 
surface, occasionally studded with plugged-up or gaping seba- 
ceous openings and covered with adherent sebaceous scales, and 
its place of election, the nose and cheeks, that it can scarcely 
be mistaken for any other disease. It is to be distinguished 
from lupus vulgaris by the absence of papules, tubercles, and ul- 
ceration. The sebaceous glands are not affected in lupus vul- 
garis. Lupus erythematosus rarely begins before puberty; lupus 
vulgaris usually begins in childhood. Lupus vulgaris is a deep- 
seated disease, and is attended, sooner or later, with ulceration 
and disfiguring cicatrices; lupus erythematosus is comparatively 
superficial. Psoriasis sometimes resembles lupus erythematosus 
very closely, but may be distinguished by its course and by the 
various symptoms peculiar to it. Syphilis sometimes resembles 
lupus erythematosus superficially, but its history is very different. 

The results of treatment in lupus erythematosus are extremely 
varied. In one case the therapeutic measures employed will 
prove rapidly and easily successful, while in another apparently 
equally light case every known method of treatment may be 
exhausted without producing more than a temporary effect on 
the course of the disease. Besnier says that nothing is more 
deceptive than the therapeutics of lupus erythematosus, even 
allowing for recent incontestable advances. Spontaneous cures, 
speedy success with the most simple and the most diverse 
methods, frequent relapses, often failure, even when recourse 
is had to the most active measures — this is what the practitioner 
has to expect in the treatment of lupus erythematosus. Internal 
remedies are called for in some cases. They are to be selected 
to meet the especial indications which may be manifested. 



LUPUS ERYTHEMATOSUS. 305 

Iodine, arsenic, iodide of potassium, and cod-liver oil may, 
one or another, often be employed with advantage. Hygienic 
measures, chiefly nourishing diet, fresh air, and sea bathing, 
are important. 

The external treatment is that which will usually be found 
most available and of the greatest value. In the milder forms 
of the disease it is to be remembered that patches often disappear 
without leaving a scar. Care must be taken, therefore, not to 
make matters worse than they would naturally turn out. No 
strong caustics are to be used in such cases. Stimulating ap- 
plications may be first tried. The following mild stimulant is 
useful when the patches are more erythema-like in appearance, 
recent, spreading, and superficial, with little infiltration and no 
involvement of the sebaceous glands: 

1$. Zinci sulphat., 

Potassii sulphuret., aa oj ( 4-) 

Aquae. §iv. (128.) M. 

If this is too strong, it may be diluted, but if it agrees, the 
first two ingredients may gradually be increased in quantity 
to four drachms (16). 

A 10 per cent, to 20 per cent, salicylic acid rubber plaster 
may be employed at times to advantage. 

Sapo viridis is also a good stimulant application, relieving the 
disease by itself alone when used in mild cases. It may be 
applied spread upon cloth in the form of a plaster, or rubbed 
in with water. Dissolved in one-half its weight of alcohol, 
it forms the "spiritus saponis kalinus," of even more value 
as an outward application. The patches are to be well scrubbed 
with the spirit, until any scales that may be present are removed, 
when it may be washed off with water and some mild ointment 
applied. Mercurial ointment is useful in some cases, prepared 
as a plaster, and applied continuously. Sulphur may sometimes 
prove serviceable applied in the form of an ointment, a drachm 
(4.) or more to the ounce (32.). Pyrogallic acid has been used 
with success in the form of an ointment, a scruple to a drachm 
'1.34-4.) to the ounce (32.), or in collodion. This, it must be 
20 



306 DISEASES OF THE SKIN. 

remembered, is a semi-caustic, and its effects must be watched. 
Stronger and even caustic applications are demanded in some 
cases, but they should never be used until the weaker ones have 
been tried. A solution of caustic potash, one part to three or 
six of water, is one of the best of these. It may be applied by 
means of a charpie brush upon a stick. Fuming nitric acid may 
also be used; it is less painful than the potash. As a general 
thing the milder applications are best. 

The galvano-cautery has sometimes been used with suc- 
cess, as also has the curette or scraping spoon, but in cases 
demanding, from their extent and infiltration, such strong 
measures, the practice of linear scarification is better than any 
of the caustics or other strong remedies just mentioned. This 
may be carried out by using a fine scalpel or tenotome, or the 
multiple scarifier (see under L. vulgaris), holding it in the 
hand like a pen, and making a series of parallel incisions about 
one-sixteenth of an inch apart, and extending entirely through 
the skin. Having covered the patch to be operated upon with 
a series of incisions running in one direction, a fre^h series, 
perpendicular to the first, should follow, and even a third series 
may be practiced, until the diseased skin is fairly hashed up by 
the knife. Excepting in persons of particularly tough fibre, 
it will be necessary to freeze the skin, with a little bag of ice 
and salt, or by means of ether or rhigolene spray, before operating. 
Bleeding may be checked by the application of absorbent cotton 
with pressure. Successive patches of a square inch, more or 
less, may be operated on daily, until the entire surface has been 
covered. The wounds should be dressed with some antiseptic 
preparation, as europhen or aristol. When the wounds are 
healed, which will be very soon, the operation can be repeated 
on any patches that may have escaped. Scarification thus accom- 
plished leaves little scar, and gives more satisfactory results 
than any other treatment of the kind. 

I have recently used the X-ray with considerable success, and 
can recommend this form of treatment in suitable cases. It is 
not adapted to recent patches or where the erythematous element 



SYPHILIS. 



3°7 



is prominent, but where the disease is more chronic, especially 
when the glandular involvement is marked, it offers an excellent 
method of treatment. 



SYPHILIS. 

The syphilitic eruptions of the skin are characterized by 
certain features in common. These are: i. Polymorphism. 




Fig. 53. — Syphiloderma erythematosum. {Courtesy of Dr. Stelwagon.) 

2. Peculiar color. 3. Rounded form. 4. Apyretic, indolent, 
non-itchy character. 5. Curability by mercury. 

They will be conveniently considered under the following 
heads: I. Erythematous. II. Pigmentary. III. Papular. IV. 



308 DISEASES OF THE SKIN. 

Vesicular. V. Pustular. VI. Tubercular. VII. Gummatous. 
VIII. Bullous. 

The erythematous or macular syphiloderm is the earliest and 
one of the commonest manifestations of syphilis, but occur- 
ring, as it often does, upon the covered parts of the body, and 
giving rise to no subjective symptoms, it often passes unnoticed. 
It comes out from the sixth to the eighth week after the appear- 
ance of the chancre, but when mercury has been given from the 
first its advent may be very much delayed. It presents itself 
in the form of diffuse macules of various sizes, and of a pale rose, 
later a brownish or yellowish tint. It is usually seen on the 
sides of the body and on the abdomen, chest, and back, also 
on the flexor surfaces of the limbs, rarely upon the face and hands. 
The diagnosis of the erythematous syphiloderm is usually not 
difficult. It is commonly accompanied by some of the other 
symptoms of syphilitic infection, general malaise, nocturnal 
headache, wandering pains in the limbs, sore throat, etc.; while 
not infrequently traces of the chancre, and the engorgement of 
the inguinal, sub-occipital, and other glands, can be made out. 

The erythematous syphiloderm runs a slow course, and is 
often accompanied, toward the last, by papular and other lesions, 
showing the polymorphous nature of the disease. 

The pigmentary syphiloderm {leukoderma syphilitica) is a rare 
manifestation. According to Taylor, three forms are encount- 
ered: (i) Spots or variously-sized brownish patches. (2) More 
or less diffused brownish discoloration which subsequently 
becomes the seat of small, spotty leukodermic changes, which 
increase in size, and the general appearance of which is reti- 
form. (3) An abnormal or uneven distribution of pigment, 
the surface having a dappled or marbled appearance. 

The pigmentary syphiloderm is most frequently found on 
the lateral and posterior surface of the neck but sometimes it 
may also affect the lateral aspects of the chest, the epigastric 
region, and the thighs. It usually appears from the third to 
fifth month of the disease or a little later and may last from a 
few months to several years. It is refractory to treatment. 



SYPHILIS. 309 

The exact nature of the eruption is not certain. Some authors 
describe it as parasyphilitic, others as a vitiligo or chloasma 
resulting from cachexia or as the trace of some previous erup- 
tion. 

The papular syphiloderm is characterized by the appearance 
of small, hard, solid elevations of various size, not containing 
fluid, and of a coppery or ham-red color, terminating in resolu- 
tion. It assumes various forms, small and large, scaly, moist 
and vegetating. The small papular syphiloderm consists of 
single and disseminate or grouped, pin-head to small pea-sized, 
hard, round, or pointed papules, at first bright red in color, 
but later of a dusky tint. It is a well-marked eruption, generally 
occupying a considerable area, and found commonly about the 
shoulders, arms, trunk, and thighs. 

The small papular syphiloderm may occur, as one of the 
early manifestations, as early as the third or fourth month, or 
it may occur later, after other lesions have occurred. Relapses 
are not infrequent. Other lesions, as large papules, small pus- 
tules, and moist papules are apt to be present at the same time. 
It is most likely to be mistaken for eczema, especially when it 
itches slightly, as it does at times, on its first appearance. It 
may also be mistaken for psoriasis. A reference to the de- 
scription of these affections will show their distinguishing features. 

The large papular syphiloderm is, in some respects, similar 
to the smaller variety, but is met with in other localities, and 
shows fewer as well as larger lesions. Its favorite seats are 
the forehead, just beyond the scalp (corona veneris), about the 
mouth, nape of the neck, back, flexor surface of the extrem- 
ities, scrotum, labia, perineum, and margin of the anus. It is 
one of the commonest of all the syphilitic skin diseases. It may 
occur early or late, .but it is very apt to follow closely on or accom- 
pany the erythematous syphiloderm. This variety is more 
amenable to treatment than the small papular, excepting where 
it takes on the annular or serpiginous form, when it may prove 
very stubborn and persistent. 

The moist papule (sometimes called "mucous patch," though 



3IO DISEASES OF THE SKIN. 

this term should be restricted to lesions occurring on mucous 
membranes) is the ordinary papule, with its horny epithelial 
surface macerated off, usually on account of the contact of two 
contiguous surfaces, as in the neighborhood of the anus and 
scrotum and about the mouth. The surface of these patches 
is dusky red, moist, and secreting. These lesions are the most 
dangerous, as to contagion, of all syphilitic lesions, and quite as 
many cases of chancre are derived from these moist papules and 
from true mucous patches of the inside of the mouth as from 
chancres. The favorite seats for moist papules are the glans 
penis and scrotum in the male, the external genitals in the fe- 
male, the umbilicus in infants, and the edge of the mouth and 
the anus in all three. The diagnosis rarely presents any diffi- 
culty, because there are almost always concomitant lesions. 

Occasionally the moist papule takes on a luxuriant papillary, 
warty growth, when the lesions are called vegetating papules. 
They resemble, but are on no account to be mistaken for, the 
non-syphilitic, "venereal," or acuminated wart. The secre- 
tion of the vegetating papule is highly contagious. It dc3s not, 
however, produce another vegetating lesion on the person inoc- 
ulated, but an ordinary chancre. 

The papulo-squamous syphiloderm is a papular eruption where 
the scaly element is prominent. It is chiefly interesting because 
it is apt to be mistaken for psoriasis — a misfortune rendered 
much more likely to happen by the perversity of some writers 
who call this lesion "syphilitic psoriasis," a misleading and con- 
fusing term, which should never be employed. The chief ele- 
ment of distinction lies in the fact that psoriasis is altogether 
a scaly disease, with but little infiltration, while the papulo-squa- 
mous syphiloderm shows comparatively few scales, with a hard, 
sometimes raised base. 

The syphilitic disease is not uncommonly found on the palms 
and soles, while psoriasis is very rarely found in this locality. 

The vesicular syphiloderm, sometimes called the varicella form 
syphiloderm, occurs as an eczemaform eruption or, in herpes- 
or varicella-like groups, sometimes mingled with the papular 



SYPHILIS. 311 

and pustular forms of the disease. The vesicle generally has a 
dusky red, solid, papular, base; it soon develops into a vesico-pus- 
tule or pustule, the apex dries up and a small papule remains 
which gradually disappears, leaving a dark stain. It is an exces- 
sively rare form of the disease. 

The pustular syphiloderm occurs in a variety of forms. The 
pustules vary greatly in size, but are all characterized by the 
rapidity with which they crust, a rapidity increasing with the 
size of the pustule. The small pointed pustular eruption is 
abundant and usually occurs with some other characteristic 
lesions; it presents no peculiarities of interest except that, as it 
matures, the epidermis around the lesion raises and forms a 
ring or collarette which is very distinctive. The large pointed 
pustular syphiloderm is the eruption which used to be called 
"syphilitic acne," a confusing designation. The pustules resem- 
ble those of acne, and still more those of small-pox, and when 
they occur upon the face, accompanied with high fever, care must 
be exercised in examining all the concomitant symptoms, or 
a mistake in diagnosis may be made, and a syphilitic patient 
thrust into a small- pox hospital. The crusts which result from 
the drying up of the pustules rest upon little ulcers, and this 
gives an important diagnostic point. For if, upon lifting a 
crusted pustule, it displays a little well of pus beneath it, the lesion 
is syphilitic, while if only an excoriation is seen, the lesion is 
almost certainly not syphilitic. In addition to acne and small- 
pox this syphilitic eruption is apt to be confounded with the io- 
dide of potassium eruptions. (See Dermatitis medicamentosa.) 

The small, flat, pustular syphiloderm is made up of small, 
flat pustules aggregated in groups and rapidly crusting. It 
occurs chiefly about the nose, mouth, in the beard, on the scalp, 
and about the genitalia. On lifting the crusts a shallow or deep 
ulcer is found. It may be mistaken for impetigo or eczema, 
but ulcers are not found in those affections. It is one of the 
more benign syphilodermata. 

The large, flat, pustular syphiloderm shows itself in finger- 
nail-sized, flat pustules on a deep red base. Sometimes the 



12 



DISEASES OF THE SKIN. 



ulcer underneath is shallow, at other times deep, punched out, 
and secreting an abundance of pus, which may dry up in thick, 
oyster-shell-like crusts (rupia). The shallow ulcerated pustules 




Fig. 54. — Syphiloderma. The large flat pustular variety. 
{Courtesy of Dr. Stelwagon.) 

of this variety are benign. The deeper ulcers generally occur 
in broken-down individuals, and are of more unfavorable signif- 
icance. They can hardly be mistaken for any other disease. 
They occur in the ninth to the twelfth month of syphilis. 



SYPHILIS. 313 

The Tubercular Syphiloderm. The eruption here consists 
of one or more solid elevations of the skin, varying in size from 
a split pea to a hazel-nut; smooth, glistening, rounded or some- 
what pointed, hard and felt to be deeply seated. Their color 
varies from a brownish-ham color to a bright red or true copper 
color. Sometimes they have an intensely dusky red hue, a 
color not met with in any other disease of the skin. 

The lesions may occur singly or grouped, sometimes in circles 
or crescents, occasionally melting together in indurated patches. 
Usually only a few lesions or a small patch occurs. This erup- 
tion is never diffused over a large area. 

Sometimes the tubercular lesions are grouped in a serpiginous 
form, and occasionally they ulcerate and crust, but not to a 
marked degree. The eruption is indolent and occurs late in the 
history of the disease, rarely showing itself before the second 
year. Not infrequently its appearance is delayed to five, ten, 
even twenty years after the initial lesion, and in women, where the 
initial lesion and early symptoms are often overlooked or ignored, 
and no history of syphilis can be obtained. Now and then 
vegetations may spring up on the tubercular syphiloderm, form- 
ing wart-like and cauliflower excrescences, with a fetid secretion. 

The tubercular syphiloderm is peculiarly liable to be mis- 
taken for lupus vulgaris. The tubercles of syphilis, however, 
are firmer, more deeply seated, and have a history of more rapid 
development. Lupus, moreover, appears usually first in child- 
hood, while the tubercular syphiloderm is rarely seen before 
adult or middle age. Occurring on the face and especially in 
the region of the cheeks and canthus of the eyelids, the ulcerative 
tubercular syphiloderm may be mistaken for epithelioma, and 
this is the more easy because the syphilitic ulcer sometimes 
becomes converted into an epithelioma. The touchstone of 
treatment must be used here, and if the suspicious ulcer fails 
to yield to mercury and iodine it should be cauterized or excised. 

The Gummatous Syphiloderm. Gummata are among the later 
lesions of syphilis. They are usually situated primarily in the 
connective tissue, and only subsequently make their appearance 



314 DISEASES OF THE SKIN. 

in the true skin, but occasionally the skin is first attacked and 
the gumma appears as a more or less circumscribed, slightly- 
raised, rounded or flat tumor, variable as to size and strongly 
tending to break down into an ulcer. The lesion resembles 
a blind boil abscess, with its dusky, purplish color and almost 
fluctuating sensation under the finger. Gummata are usually 
solitary. When ulceration takes place the cavity is deep, but 
fills up rapidly as a cure takes place. Gummata are apt to be 
mistaken for furuncle, abscess, enlarged lymphatic glands, 
carcinoma, and for fibrous and fatty growths. Gummata are 
occasionally poulticed and then cut open with great resultant 
chagrin to the operator, when the firm, dry walls gape, where 
pus was expected to flow. They should never be lanced, as it 
is much easier to cause resolution by appropriate remedies than 
to cure the open sore which follows cutting. 

The bullous syphiloderm is very rare. It is characterized by 
the appearance of blebs containing a clear, watery fluid, which 
soon tends to become cloudy and thick. Sometimes the lesion 
is more like a large pustule than a bleb. The lesions soor> break 
or dry up with rupial crusts. When these are removed shal- 
low ulcers are found. The bullous eruption is a late manifes- 
tation of syphilis, and is met with in the cachectic and broken 
down. It can only be mistaken for pemphigus or dermatitis 
herpetiformis, and in both of these affections the bullae contain 
serum and not pus, and rupial crusts are absent. 

The treatment of the syphilitic affections of the skin should, 
in the early diffused eruptions, be internal only. When the 
lesions are comparatively few in number and of some size, espe- 
cially when they are ulcerative, local applications may be used 
with benefit. Finally, in the late and indolent ulcerative, tuber- 
cular, or gummatous lesions, local treatment alone often suffices 
to heal the lesion, and since internal treatment, however good, 
will not insure against a relapse, it need not necessarily be used. 
Mercury is to be employed in the earlier and generalized lesions. 
The protiodide of mercury, in doses of one-fourth of a grain, in 
pill form, thrice daily, gradually increased until the disease yields 



SYPHILIS. 315 

or the gums are touched slightly, is the best average treatment. 
The biniodide of mercury is also very useful in doses of -^ to J 
grain, dissolved in water, with the aid of a little iodide of potas- 
sium, when for any reason it is preferred to give the mercury in 
a fluid form. Iodide of potassium is to be reserved for the later 
lesions, or to mix with the mercurial in stubborn cases. A dose 
of five grains will be found large enough in the great majority of 
cases, but it must be pushed rapidly if the lesions do not yield. 

In those cases where the gums are unusually susceptible to the influence 
of mercury the following formula, suggested by Unna (Monatshejt. /. Prakt. 
Dermatol., Bd. xvii, No. 9, p. 466), may be employed as a tooth powder: 

1^. Potassii chlorat., oiv (16.) 

Pulv. cretee, 

Pulv. rhizoma iridis, 

Pulv. saponis castiliensis, 

Glycerinae, aa 5 j- ( 4-) M. 

Local treatment is required when the lesions are situated on 
the face and hands, and when it is desirable to hasten their dis- 
appearance by all means, or when ulcers, with profuse and dis- 
agreeable discharge, are present in any part of the body. For 
dry lesions, the ammoniated mercury ointment, or a twenty or 
ten per cent, oleate of mercury, may be rubbed firmly into the 
skin, once or twice daily. For moist lesions, a solution or stick 
of nitrate of silver may be employed. In ulcers, bits of soft 
linen, cut a little smaller than the lesions and spread thickly 
with ung. hydrarg., full or half strength, may be applied. 

Skin Diseases in Hereditary Syphilis. The syphilitic erup- 
tions of infants are, in all respects, the same as those of adults, 
excepting in so far as their appearance is altered by the pecul- 
iarities of structure of the infantile integument. 

The mortality of syphilitic children is very great, fully one- 
third failing to reach maturity. Abortion, resulting from the 
death of the foetus, usually occurs about the sixth month. An 
aborted foetus is usually in a macerated condition, the skin being 
easily detached, and the surface having a livid purple color. 



316 DISEASES OF THE SKIN. 

The integument either shows nothing characteristic, or large 
bullae may be found on the palms and soles. 

Syphilitic children generally present a healthy appearance 
at birth, and, for a week or two, all seems to go well. Then 
symptoms of debility and decreased vitality show themselves; 
the infant begins to emaciate and grows wizened and aged in 
appearance. Catarrh of the nasal passages — the "snuffles" — 
shows itself, interfering with respiration, and thus sometimes 
itself alone being the cause of death. The skin becomes yellow, 
loose, and wrinkled. It is drawn tight over the bones of the 
face, which becomes sallow and earthy, with prominent eyes 
and a peculiar senile expression, the infant presenting the appear- 
ance of decrepit old age. Now and then, however, excessive 
emaciation is not observed, even when the syphilitic poison has 
affected the system to a marked degree. 

The erythematous syphiloderm is that which is earliest and 
most frequently observed in infants. It generally makes its 
appearance about the third week of life, often accompanied by 
coryza, and showing itself first on the abdomen, in the form of 
minute, round or oval, pink macules. It spreads rapidly over 
the surface of the body and limbs and the patches grow larger 
and darker, until they may be half an inch in diameter, slightly 
or not at all elevated above the surface, coppery-red in color, 
and no longer, as at first, disappearing under pressure. There 
is usually little or no scaliness, excepting slight desquamation, 
at times, upon the hands and feet. 

This eruption is very liable to be confounded with the simple 
erythematous rashes of early infancy. The most important 
diagnostic points are the tendency to infiltration, and the for- 
mation of papules in places where the skin comes together in 
folds, as about the neck, and especially in the region of the genit- 
alia and nates. In addition, the tendency to scaliness about 
the palms, soles, and occasionally the nates is more or less char- 
acteristic. Sometimes, however, it is impossible to distinguish 
between the syphilitic eruption and simple erythema about the 
nates, at first sight, and the case must be held under advisement 



SYPHILIS. 317 

for a certain time, local treatment only being employed, before 
a positive diagnosis can be given. The syphilitic eruption tends 
to get worse, shows moist and infiltrated patches, etc., while 
other symptoms show themselves elsewhere. The eczematous 
eruption will either improve under local treatment or tend, to 
show weeping and itchy patches, and vesicles or pustules. 

The papular syphiloderm in infants is usually met with in 
connection with the erythematous eruption, but sometimes it 
may occur first. The lesions are dull red, small, flat papules, 
occasionally mingling to form a patch. When seated about 
the anus or genitalia, the lesions become changed into typical 
moist papules, and now and then vegetations or syphilitic condy- 
lomata grow out of these lesions. These are highly contagious, 
and must be carefully distinguished from the simple vegetations 
growing about these parts in children who are poorly cared 
for. The latter are apt to be smaller, more pointed, and dark, 
and occur almost invariably near some muco-cutaneous junc- 
ture. They spring directly from the skin, while the syphilitic 
vegetations grow from an indurated, often moist, base. The 
simple vegetations are not so apt to have a fetid odor, whereas 
the syphilitic condylomata secrete an excessively offensive sero- 
purulent liquid. Moist papules in the infant are apt to occur at 
the verge of the anus and the commissure of the lips. In the lat- 
ter locality they lead to deep fissures, the scars of which form 
diagnostic marks of hereditary syphilis in later life. 

The pustular syphiloderm in infants may occur before the 
eighth week in children profoundly affected with syphilis, but 
usually shows itself at a later period. The pustules may be 
large, numerous, and deep, or few and small, according to the 
severity or mildness of the disease. The thighs, buttocks, and 
face are usually attacked. On the face they may coalesce and 
form thick, green, crusted lesions, resembling those of impetigo 
or pustular eczema. The syphilitic crusts, however, are dark, 
thick, and greenish, while those of the other diseases are fighter. 
On removal of the crusts the syphilitic lesions are found ulcerated, 
while only a shallow erosion is found under the eczema and impet- 



318 DISEASES OF THE SKIN. 

igo crust. Moreover, itching, which is very common in eczema, 
does not exist in the syphilitic lesion. 

A furunculoid eruption is sometimes met with in hereditary 
syphilis. The lesions begin as small nodules in the corium, and 
gradually increase to the size of half a nutmeg; ulcers form on 
the summit; sloughs are thrown off, and irregular, unhealthy 
cavities, with scanty, offensive secretion, are left, the lesions 
subsequently running a chronic course. They often result in 
cicatrices. 

Tubercular and bullar eruptions sometimes occur in hered- 
itary-syphilitic children; the former show no marked difference 
from similar lesions found in the adult. The bullar syphilo- 
derm, the ''pemphigus syphiliticus" of older writers, is usually 
found on the palms and soles. The skin shows patches of a 
violet color; in a short time, small, confluent vesicles make their 
appearance on these spots, and then coalesce and grow larger, 
until the fully- formed bullae show themselves, varying in size 
from that of a pea to a hen's egg, with a yellowish- green, opal- 
escent color and purulent contents. The lesions may be b *ownish 
or hemorrhagic; they break in a day or two, and leave shallow 
ulcers. The bullar syphiloderm is a symptom of grave import. 
It is important to distinguish it from simple pemphigoid erup- 
tions. This may be done by noting its earlier appearance (it is 
congenital, or appears very soon after birth), its usually more 
serious character, and the concomitant symptoms and history. 
It is rarely the only symptom. Sometimes impetigo contagiosa 
may be mistaken for the bullar syphiloderm, but its non-ulcera- 
tive character, place of election, trifling severity, etc., should 
prevent this mistake. (See Impetigo contagiosa.) 

The treatment of hereditary, infantile syphilitic skin dis- 
eases is essentially that of the disease in general. Mercury 
may be administered by baths, inunctions, or internally. 
Warm, daily baths, each containing ten grains of the bichloride 
of mercury, are frequently highly beneficial. A small flannel 
skirt, with the waist tied around the infant's neck, and then 
spread over the edge of the tub, will permit it to splash, with- 



DELHI BOIL. 319 

out danger of sending the fluid into its mouth. The dose 
is sufficient for any age, from one month to twenty. Inunc- 
tions of mercurial ointment, in full or in half strength, may be 
employed. The best procedure it to smear a piece of ointment, 
the size of a small walnut, thinly over a flannel band, and then 
pin it around the abdomen, not changing it, but applying fresh 
ointment daily, until the flannel becomes stiff. Gray powder is 
given internally by many physicians. I rarely use it as it seems 
almost invariably to derange the child's digestion. In the later 
furunculous and pustular eruptions the iodide of potassium, in 
doses of half a grain to two grains, according to the age of the 
infant, may be given with advantage. Inunctions of cod-liver 
oil, or the same internally, may be given at times, and nourishing 
and appropriate diet is absolutely required. 

DELHI BOIL. 

An endemic disease, of some parts of the tropics, characterized by the ap- 
pearance, usually on exposed parts, of one, several or more rounded papu- 
lar elevations, which slowly enlarge and usually become furuncular and 
ulcerated. 

The disease usually appears upon the face, beginning as a roundish itchy 
papule as if from mosquito bite. It gradually enlarges to the size of a pea 
or small grape, softens, opens and exudes a serous and later a sero-purulent 
fluid which dries and crusts. While the crust grows thicker and more ex- 
tensive the lesion becomes flattened down into an ulcer. The development 
is slow, several months often elapsing before the lesion reaches the ulcerative 
stage. There may be only a single lesion, several separate ones, or a con- 
glomerate which often fungates. Erysipelas, lymphangitis, etc.. may accom 
pany the disease. Finally repair sets in. The disease is inoculable and 
probably of microbic origin. The lesions, when single, may be cut or 
burned out. In conglomerate lesions curettage with subsequent cauteriza- 
tion or antiseptic applications may be employed. 

FRAMBCESIA. 

Frambcesia, called also yaws or plan, is a contagious, endemic skin disease, 
characterized by general and cutaneous symptoms, occurring in the West 
Indies and other tropical countries. The eruption consists of variously-sized 
papules, tubercles, and tumors, of a reddish or yellowish color. After a pro- 
dromal period of ten days to several weeks after inoculation the lesion appears 



320 DISEASES OF THE SKIN. 

as a yellowish or whitish point or spot, which gradually enlarges and projects 
from the surface, looking, when fully developed, like a piece of cotton wick, 
a quarter of an inch or less in diameter, dipped into a dirty yellow fluid, and 
stuck (on to the skin, in a dirty, crusted, brownish setting, and projecting to 
a greater or less extent. Or at times the lesions look like red currants, with 
flat tops, of a bright pink color, glassy, semi-transparent. Larger lesions 
look like cherries. The tubercles may be smooth, scaly, or ulcerated. The 
eruption generally manifests itself on the face, upper or lower extremities, 
and genitalia. The largest growths occur on the lips, eyelids, toes, and gen- 
ital organs. The lesions are not painful or itchy. 

Native observers long ago considered this disease contagious, but the fact 
of contagion was doubted by more scientific observers. As we now know 
that all diseases of this class are contagious, the treatment which naturally fol- 
lows would be directed to thorough cleanliness and disinfection. A med- 
icated soap should be used for purposes of ordinary cleanliness over the whole 
surface of the body at least once a day, and locally twice or three times a 
day. In addition to this the secretions should be dried off with absorbent 
cotton, dabbed with a one-thousandth solution of bichloride oi mercury, and 
then dusted with europhen, aristol, or some similar disinfectant. In some 
cases it may be desirable to cauterize the lesions, but this can hardly 
ever be absolutely necessary, because, like all the other papillomata, the re- 
moval of the cause will be rapidly followed by disappearance of the growth 
The disease should be carefully distinguished from syphilis with which the 
careless observer might confound it. 

VERRUGA PERUANA. 

Verruga is a specific inoculable affection endemic in some valleys of the 
western Andes, in Peru, and characterized by a prodromal febrile period and 
subsequent outbreak of peculiar pin-head to pea-sized or larger, reddish, 
rounded, granulomatous, wart-like elevations. 

The prodromal period is characterized by irregular fever, rheumatic joini 
and muscular symptoms and more or less anaemia, lasting weeks or months. 
When the eruption appears these symptoms vanish but may recur later. The 
lesions appear first on the face and limbs as small papules or incomplete ves- 
icles, later developing into a sort of papilloma or fungoid vegetation. The 
lesions are said to occur on the mucous and even serous surfaces. The dis- 
ease is inoculable and probably due to a bacillus. It is strictly localized as 
above stated. t 

The disease is considered grave, the death rate being about one in six or 
eight. The treatment should include tonics, etc., and when possible removal 
to a healthy seashore climate. It is said to be best not to attempt to remove 
the local manifestations but antiseptic dressings should be of value. 



CARCINOMA CUTIS. 321 

CARCINOMA CUTIS. 

The forms of carcinoma of the skin most interesting to the 
dermatologists are epithelioma or skin cancer and Paget's 
disease. Before describing these some mention may be made 
of the other varieties of carcinoma which, however, are more apt 
to come under the care of the surgeon. These are the follow- 
ing : i . Carcinoma lenticular e {scirrhous, hard, fibrous or connec- 
tive tissue cancer), characterized by smooth, glistening, dull 
pinkish- or brownish-red, flat or raised papules, tubercles or 
nodules, from pea- to bean-, or larger size, disseminate, at first 
separate, later running together, slow in its course, involving 
the neighboring glands, causing pain, breaking down, recurring 
on excision and ending fatally. 2. Carcinoma tuberosum; a 
rare affection, occurring in flat or raised, rounded or ovalish, 
tubercular or nodular lesions, from pea- to walnut-size or larger; 
firm, hard, deeply imbedded in the skin and the subcutaneous 
connective tissue, of a dull reddish, brownish-red or violaceous 
color, multiple, disseminated, or irregularly grouped, sooner 
or later breaking down into ulcers and ending fatally. 3. 
Carcinoma melanodes or pigmentodes; beginning in the form 
of multiple, small, pin-head, or bean-sized, rounded or ovalish, 
soft or firm papules, tubercles or nodules, of an iron-gray, brown- 
ish, bluish-black or blackish color, at first discrete, but tending 
to aggregate into tumor masses, and then to break down and 
ulcerate, forming often fungous, gangrenous, and pultaceous 
masses, commonly found starting in a mole or wart on the 
face or on the hands and feet, usually encountered in early adult 
or middle life, and pursuing a malignant course. 

The treatment of these forms of cancer, when early seen, 
is essentially the same as that described under epithelioma 
and sarcoma. Later they necessarily fall under the care of 
the surgeon. 

EPITHELIOMA. 

Epithelial cancer of the skin may be either superficial, deep- 
seated, or papillary. The superficial or "flat" epithelial cancer 



322 DISEASES OF THE SKIN. 

usually makes its appearance as one or more grouped, small, 
yellowish or reddish papules or elevations, having their seat 
in the upper layers of the skin. The disease may originate in 
a sebaceous gland, wart, or other growth, or in the form of a 
flat infiltration. After a time, it may be months or even years, 
the tubercle, wart, or infiltration, as the case may be, becomes 
fissured or excoriated, a slight brownish crust forms upon it, 
under which is a scanty, watery, or viscid secretion. The course 
of the disease is slow, but gradually new lesions appear, usually 
connected with the original one, and finally the tubercles break 
down, and ulceration of a superficial character sets in. The 
ulcer, at first small, may spread until it attains the size of a coin, 
or even of the palm of the hand. The ulcer is characteristic. 
It is usually roundish, but may be quite irregular, with either 
sloping or sharply defined edges. The border may be smooth 
and on a level with the skin, but is usually elevated into a pearly 
ridge all around the ulcer. Its base is usually hard, and secretes 
a scanty, viscid fluid; it bleeds readily. There is usually a 
peculiar and characteristic picking or crawling sensation in the 
lesion when it first begins to become fissured or excoriated, but 
there is usually no pain unless the ulceration is considerable. 
When fully developed the ulcer may remain in statu quo for an 
indefinite period, the patient's health, meantime, being excellent; 
or it may pass into the infiltrating, deep-seated variety, to be 
described. The lymphatic glands are not involved. 

Rodent ulcer is a form of this variety of epithelial cancer. 
Its most frequent seat is upon the eyelids, particularly near the 
inner canthus, and next to this upon the side of the nose. When 
fully developed it consists of a circumscribed, sharply defined, 
greater or less excavation, with a brownish-red or purplish-red, 
dry, or scantily secreting, mammillated surface, the ulcer having 
often a rolled border. Its course is very slow but relentless; 
it invades every tissue with which it comes into contact, including 
muscles and bones. If neglected, great destruction of the parts 
may ensue, and even death from hemorrhage in very advanced 
cases. A peculiarity of this form of epithelioma is, that it is a 



EPITHELIOMA. 



3 2 3 



disease of the upper part of the face, occurring usually above a 
line drawn across the face horizontally, on a level with the alae 
nasi and the lower border of the ears. 

Deep-seated Variety. This variety of epithelioma, known 
also as the "infiltrating" variety, is much more serious than the 
superficial variety of the disease. It begins as a split-pea- 
sized tubercle, situated in the skin and subcutaneous connective 
tissue. It sometimes, however, begins in a wart, like the super- 




FiG. 55. — Rodent ulcer. {After Cantrell.) 



fkial variety. It is reddish or purplish in color, surrounded 
by an areola, firm and hard to the touch, and accompanied by 
infiltration of the surrounding tissues. In a longer or shorter 
time, according to the malignancy of the case, usually months, 
ulceration begins, either from within or upon the surface, 
the tumor breaks down, and an ulcer of variable size results. 
This is deeply excavated, irregular in shape, with a violaceous 



324 DISEASES OF THE SKIN. 

base, secretes a viscid, offensive fluid, bleeds freely upon being 
touched, and is surrounded with infiltration, the skin being 
reddish in the neighborhood. The lymphatic glands become 
enlarged at a later period, the lancinating pains, which are often 
experienced from the beginning, become more severe, the pa- 
tient suffers extremely and finally succumbs through marasmus 
and exhaustion. The course of this disease, though sometimes 
slow, is occasionally rapid. Duhring alludes to a case where 
the disease ran its fatal course in a year. 

Papillary Variety. In this variety of epithelioma, the lesion 
begins as a wart of split-pea size, or occasionally as a raised, 
lobulated, more markedly papillary formation of larger area. 
The surface is sometimes covered with dry, horny, epidermic 
scales, at other times it is moist and macerated. There are 
usually fissures secreting an offensive fluid, with sometimes 
cheesy, sebaceous matter. The fungous-looking granulated 
surface sometimes develops into fleshy protuberances, and at 
other times spreads out more flatly. After a time it breaks 
down into a characteristic epitheliomatous ulcer, running the 
usual course. Occasionally the papillary growth proceeds 
from a preexisting superficial or deep, infiltrated ulcer. 

Epithelioma is most commonly met with on the face, either 
on the lips or tongue, about the nose, the eyelids, the forehead, 
the temples, or upon the scalp. The genitalia, especially the 
penis and the scrotum in the male, and the labia in the female, 
are not uncommon seats of the disease. Epithelioma rarely 
occurs elsewhere, although it may be found in any part of the 
body. The lesion is usually single. 

The exciting causes of epithelioma are often obscure. Epithe- 
lioma of the lip or tongue often starts at a point where the mucous 
membrane has been irritated by a pipe-stem or a jagged tooth. 
Chronic pruritus of the anus or vulva and congenital phimosis 
may in time be followed by epithelioma, which also occasionally 
originates in cicatricial tissue or in old ulcers. Warts and naevi, 
both pigmentary and vascular, are structures in which it often 
originates. The sebaceous warts of old persons seen so fre- 



EPITHELIOMA. 325 

quently upon the face, the backs of the hands and the scapular 
region, often form the starting-point of epithelioma. Tumors 
of the skin called "benign," as fibroma molluscum, may become 
transformed into epithelioma. Psoriasis, also, as has been 
pointed out by Dr. J. C. White and others, may gradually develop 
into verruca and then into epithelioma. The disease known 
as "xeroderma pigmentosum" is allied in some of its aspects with 
epithelioma, as epitheliomatous growths occur in one stage of 
the affection in many cases. Lupus and syphilis of the skin may 
also become transformed into epithelioma. The disease is com- 
moner among men than among women. It is less malignant 
than any other form of cancer. 

Pathologically the epitheliomatous process consists in the 
proliferation of epithelial cells — pavement epithelium — from 
the epidermis or from the epithelium of the hair follicles or 
glandular structures or from the mucous membrane. The 
cell growth takes place downward, in the form of finger- like 
prolongations or columns, or it may spread out laterally or deeply 
so as to form rounded masses, the centers of which usually 
undergo horny transformation, resulting in the formation of 
onion-like bodies, the so-called "pearls," cell-nests," or "globes." 
The rapid cell growth gives rise to irritation and inflammation 
and increased blood supply with serous and round-cell infiltra- 
tion. There are two histological types, the lobulated and the 
tubular. In the first the cells are massed in globular aggre- 
gations, while in the tubular or cylindric type the epithelial 
growth is in the form of cylindric processes anastomosing with 
one another and sometimes presenting a pseudo-glandular ap- 
pearance. 

Bodies thought to be organisms have been found in epithe- 
lioma but these observations have not been generally accepted 
as accurate. 

The diagnosis of epithelioma is usually not difficult, excepting 
in the earlier stages. It may be confounded with syphilitic 
tubercles and ulcerations, warts, and lupus. The papule or 
ulcer of epithelial cancer, especially if about the genitalia, may 



2,2b DISEASES OF THE SKIN. 

also resemble chancre; but the history of the case, the duration 
of the lesion, and a careful examination of its features, will aid 
in arriving at a correct opinion. The later syphilitic manifes- 
tations run a much more rapid course, and change in appearance 
more rapidly than epithelioma, and, when ulcerative, their secre- 
tion is much more abundant and purulent. Nevertheless, it is 
not rare, in my experience, to see cases of epithelioma about 
the face, which have been mistaken for the tubercular syphilo- 
derm, and vice versa. What lends additional difficulty to the 
diagnosis in these cases is, that, as mentioned above, the syphilitic 
lesion now and then becomes transformed into epithelioma. 
I recall the case of a middle-aged woman showing a small ulcer 
near the inner canthus of the eye, which, after some hesitation, 
was pronounced syphilitic, and being treated with iodide of potas- 
sium healed up, returning again six months later, however, as 
unmistakable epithelioma, and quite uninfluenced at this time 
by the anti- syphilitic treatment. In making a diagnosis between 
syphilis and epithelioma in any case, the points mentioned 
should be borne in mind, and also the facts that the ti .bercular 
syphiloderm when ulcerating, usually shows several points of 
suppuration, while epithelial cancer is commonly single, and 
also that there is induration under and about the cancerous 
sore, while the syphilitic ulcer terminates abruptly against the 
sound skin. Finally, in cancer there is usually a picking and 
crawling sensation at first, and later lancinating pain. Syphilis 
is painless. 

Many epithelial cancers begin as warts, and it is often difficult 
to distinguish between a simple wart and a cancerous wart. 
Usually continued observation alone will decide. In elderly 
persons any change in a wart of old standing upon the face, 
especially those flat, brown warts, not uncommon in advanced 
life, must be looked upon with suspicion. 

From lupus vulgaris, the diagnosis of epithelial cancer is 
chiefly to be made by the history. Lupus is a disease usually 
beginning in early life, and commonly has a long history. It 
is apt to be found in more parts of the body than one. When 



EPITHELIOMA. 327 

ulceration takes place, the diagnosis becomes more difficult, 
but a careful examination of the surrounding parts will com- 
monly show some characteristic lupus lesions in the neighbor- 
hood. The discharge from a cancerous ulcer is usually pale, 
scanty, and viscid, and is often offensive; that from lupus is 
yellowish and puriform, and is not offensive. 

The treatment of epithelioma is external and local. Only 
the more superficial forms are apt to come under the care of 
the dermatologist, the more severe forms usually seeking the 
aid of the operative surgeon. 

It should be remembered that every source of irritation is 
in reality a cause of aggravation, and that, therefore, epithe- 
lioma is to be attacked only to be destroyed. All temporizing 
applications, like nitrate of silver, etc., merely add fuel to the 
flame, and aggravate the disease they are intended to cure. 
For this reason I shall not speak of several remedies which 
are mentioned as curative in this affection, as resorcin, chlorate 
of potassium, etc., because I think they are not thorough and 
^effectual. 

There is one preparation which has the sanction of time and 
experience to recommend it, and which has been imitated by 
quacks with great success, that is " Manec's paste." This is com- 
posed as follows: 

1$. Acidi arseniosi, 9j ( 1.30) 

Hydrarg. sulphat., §ij (32. ) 

.Spongiae ustae, 3iv. (16. ) M. 

The ingredients should be powdered and mixed thoroughly and pre- 
served in a tightly stopped bottle. 

When needed, the amount necessary is to be mixed with a 
sufficient quantity of water to make a paste. The epitheliomat- 
ous patch to be operated upon must first be cleansed com- 
pletely of all crusts and detritus by the employment of poultices, 
etc. Then, the paste having been spread upon a bit of lint ac- 
curately fitted to the size of the lesion, this is to be applied and 
firmly attached by strips of adhesive plaster. The application 
must be retained in place from one to two weeks. At the end 



328 DISEASES OF THE SKIN. 

of this time the eschar falls off, carrying with it, it is to be 
supposed, the entire neoplasm. 

For my own part (while admitting the value of this paste on 
the testimony of many experienced dermatologists), an exper- 
ience of many years induces me to favor the use of caustic potash, 
which never fails to remove these superficial epitheliomata when 
used judiciously and thoroughly. A stick of caustic potash is 
to be wrapped in a piece of lint or placed in a suitable holder, 
leaving only the point exposed, and this is passed over the 
growth, gently at first, to dissolve the horny epithelium, when 
this exists, and then the potash stick is to be bored into every 
part of the substance of the growth. While operating, the un- 
healthy tissues are found to give way very readily, so that 
it may easily be perceived, by the increased resistance 
offered, when the caustic reaches sound tissue. It must be 
remembered that the action of the potassa always proceeds 
a little further after the caustic has been withdrawn. This 
must be borne in mind when operating in the neighborhood of 
important organs, as the eye, or where arterial branches may 
become involved. The application of the caustic potassa gives 
rise to severe pain, which, however, rapidly ceases after its with- 
drawal. Pain may be prevented to some extent by applying 
a four to eight per cent, solution of cocaine to the part before 
operating. When the effect has proceeded as far as is desirable, 
the application of dilute acetic acid or weak vinegar will neutralize 
the caustic influence, and put an immediate end to the pain. 
There is rarely any hemorrhage. The part operated on may 
be dressed with europhen powder or other suitable antiseptic 
powder or ointment. The dressing is to be changed daily, 
and the eschar usually falls off at the end of ten days or two 
weeks, after which a rapidly granulating surface ensues, ending 
in an insignificant scar. 

Pyrogallic acid in an ointment of ten to twenty per cent, 
strength, applied on patent lint, from two to six days consecutively, 
is a good remedy in certain cases, particularly when the patient 
cannot bear pain. It is usually painless. It may have to be 



paget's disease. 329 

reapplied, from time to time, the slough being cut or scraped 
away as it forms. Pyrogallic acid should not usually be trusted 
in the patient's hands, as too much action may be produced, 
or the effect may penetrate too deeply. 

Among other means of removing epithelioma the galvano- 
cautery, especially in operations near the eye, is recommended 
by those who have used it. Scraping with the dermal curette, 
or sharp spoon, alone, or followed by the actual cautery, is 
another mode of removal. For the use of the knife, which is 
not needed in the majority of superficial epitheliomata, if these 
are taken in time, reference may be made to the standard works 
on surgery. 

Of late the Rontgen or X-ray has been used very successfully 
in the treatment of epithelioma and although not by any means 
superseding the forms of treatment detailed above will, in care- 
ful hands, prove an important aid to the treatment of certain 
forms of the disease. The scope of the present work will not 
permit a description of the technique, for which the reader is 
referred to the special works on X-ray treatment. 

PAGET'S DISEASE. 

"Paget's disease of the nipple" is a malignant disease, usually 
occurring in the nipple and adjacent structures and at first closely 
resembling eczema. The disease begins with roughness, redness, 
and scaling about the center of the nipple, with occasional 
slight oozing or crusting, and, in some cases, the formation of 
a fissure. The process goes slowly on, presenting to all appear- 
ance the symptoms of eczema with intense itching, in many 
cases the nipple becoming retracted and finally melting away. 
When fully developed a considerable portion of the breast may 
be covered by the red, infiltrated, weeping patch, which is slightly 
sunken at the sharply defined edge below the level of the surround- 
ing skin, and presents a peculiar livid crimson, different in tint 
from the bright red of eczema rubrum. Taken between the 
fingers, the infiltration of the skin does not extend as deeply as 
would be thought from the appearance of the disease. The 



330 • DISEASES OF THE SKIN. 

points just given, together with the fact that the infiltration is 
firmer than that observed in eczema, and that the surface exudes 
a serous fluid without much discharge, crusting, vesiculation, 
etc., will serve to distinguish the disease from eczema of the 
nipple, with which it is very apt to be confounded. Any eczema 
of the nipple should, however, be viewed with suspicion, above 
all if chronic in character, tending to spread slowly and steadily, 
and with more or less progressive retraction of the nipple. 
Though usually occurring in the nipple and breast, Paget's 
disease is sometimes found elsewhere, as about the genital 
region in both sexes, on the face, nose, etc. 

The morbid changes in Paget's disease, according to Fordyce 
may be briefly stated as inflammation of the papillary region 
of the derma, leading to an oedema and vacuolation of the con- 
stituent cells of the epidermis, followed by their complete de- 
struction in places and their abnormal proliferation in others. 
The lactiferous canals and glandular epithelium may be changed 
by a secondary process. 

As regards treatment, in the earliest stages when eczema 
alone is probably existent, the treatment for this disease may be 
employed. It is reasonable to suppose that such a disease as 
simple eczema of the nipple exists in a certain number of cases. 
But if the eczema does not quickly yield and if the peculiar 
symptoms of Paget's disease begin to appear, the treatment 
of malignant disease is called for, and here I am inclined to 
favor surgical interference at an early date. In selected or 
doubtful cases or when operative procedures are declined the 
X-ray treatment may prove successful. 

XERODERMA PIGMENTOSUM. 

This affection, sometimes also called "angioma pigmentosum et atroph- 
icum " is a malignant disease, usually developing in early life, characterized 
primarily by freckle -like spots, especially upon exposed surfaces, followed by 
telangiectases, atrophic changes, angiomatous and verrucous lesions, with 
increased pigmentary deposit, and, finally, after some years, by epitheliomat- 
ous growths and fatal ending. The disease is very rare, only some eighty 
cases being on record. It begins almost invariably in the first years or even 



SARCOMA CUTIS. 33 1 

months of life and may last for years, the patient finally dying of exhaustion 
or marasmus. Several cases may occur in a single family. 

The pathology of the disease is obscure. The various lesions display the 
histological character which their appearance respectively denotes. 

Xo satisfactory treatment can be suggested beyond the applications suit- 
able to the various lesions as they develop. Stel wagon suggests the pro- 
longed employment of hypodermic injections of arsenic. The prognosis is 
unfavorable.* 

SARCOMA CUTIS. 

Sarcoma of the skin appears in the form of shot, pea, hazel-nut, or larger 
sized, variously shaped, discrete, non-pigmented or pigmented tubercles, or 
tumors. Non-pigmented tumors, occurring as single or multiple growths 
upon the various regions, represent, perhaps, the commonest manifestations 
of the disease. They are smooth, firm, elastic, not markedly painful upon 
pressure; in color, reddish, violaceous, or brownish-red. Two other varie- 
ties are also described, the melanotic sarcoma and the multiple pigmented 
hemorrhagic sarcoma. It is said that the multiple pigmented sarcoma al- 
ways appears first upon the soles and backs of the feet. The disease may 
be mistaken for the papular or for the gummatous syphiloderm, lupus and 
lepra. It occurs generally toward middle age. The growths of the non- 
pigmented variety are made up chiefly of round cells or mixed round and 
spindle cells. In the earlier stages of development these form nodular col- 
lections at the junction of the cutis and subcutaneous cellular tissue. Occa- 
sionally a fibrous or lymphatic element is predominant. Pigmentation, 
when this is present, is due to capillary hemorrhages. The disease is malig- 
nant, usually proving fatal in the course of a few years. Recently, hypo- 
dermic injections of Fowler's solution, in the dose of two drops, gradually 
increased to nine drops, diluted with two parts distilled water, daily, have 
been used successfully. The X-ray treatment has been said to have proved 
successful in one or two cases. 

GRANULOMA FUNGOIDES. 

Granuloma jungoides or mycosis fungoides is a chronic malig- 
nant disease characterized usually by precursory symptoms of 
months or years duration, of an eczematous, urticarial or erysip- 
elatous aspect, with the subsequent appearance of pinkish 
or reddish, tubercular, nodular, lobulated or furrowed tumors 

*See Kaposi, Wien. Med. Jahrb., 1882, p. 619, and Taylor, N. Y. Med. 
Record, Mar. 10, 1888. For recent literature of. Stelwagon. 



33 2 DISEASES OF THE SKIN. 

or flat infiltrations, which frequently ulcerate and form fungoidal 
or mushroom-like growths. 

The symptoms characteristic of mycosis are variable at 
different periods of the disease. At first, bright red erythem- 
atous patches on a level with the skin, or slightly raised above 
the general surface, appear at one or more points, accompanied 
by pruritus. These occasionally resemble the lesions of urticaria — 
in fact, urticarial patches have been observed in some cases. 
Later the lesions become covered with scales, or vesicles and 
papules, or may become raised, hard, and fissured, assuming 
somewhat the appearance of chronic, infiltrated eczema papillo- 
sum ("lichen"). At other times they may diminish and dis- 
appear like eczema, without leaving a trace. While these ery- 
thematous or lichenoid lesions mark the earlier stage of the 
affection, sooner or later, after months, or perhaps years, it takes 
on the more especial features which give mycosis its peculiar and 
characteristic aspect. On, or alongside of, the lichenoid patches, 
vegetations and growths occur, at first wart-like, later profusely 
hypertrophic — frambcesioid lesions. Once formed, these lesions 
increase rapidly in size, and they may attain the dimensions of a 
cherry-stone, an almond, or a small orange. They are red, 
sometimes violaceous, vascular, somewhat firm, of uneven sur- 
face, so as sometimes to resemble tomatoes. The growths may 
be solitary or grouped and united at the base, but separated at 
the summit. 

The surface of the hypertrophied tumors is a first dry, smooth, 
and sometimes slightly scaly. The pruritus, a marked symptom 
of the early lesions, diminishes at this stage, and there may be 
even a slight diminution of sensibility, and any hairs which may 
grow from the surface are apt to fall out. 

After continuing in this state for a considerable time the tumors 
may suddenly change in one of two quite diverse directions. 
Either they may, as some do, undergo rapid interstitial absorp- 
tion, become retracted, shrivel up and disappear, without leaving 
any trace, in ten to twenty days, or, on the other hand, they may 
become moist and crusted, or break down and suppurate pro- 



GRANULOMA FUXGOIDES. 



333 



fusely, with an ichorous discharge. Now and then the body of 
the tumor remains firm, while a crater-like cavity forms in its 
center, and in rare cases the new growth, followed by destructive 




Fig. — Granuloma (mycosis) fungoides. (After De Amicis.)* 



metamorphosis, may go beyond the skin and penetrate the sub- 
jacent tissues to the very bone. 

Simultaneously with the development of the skin lesions the 
lymphatic glands, especially those in the axillae, groins, and 
cervical regions, increase in size and become painful. While 

*Contrib. clin. ed anatomo-patholog alio studio del Dermo-linfo-adenoma. 
Fungo de micosi. di Alibert. Napoli, 1882. Abst. Annales de Dermet de Syph, 
1882, p. 452. 



334 DISEASES OF THE SKIN. 

these glands may attain a considerable size, they rarely suppur- 
ate. 

In the earlier stages of the disease patients usually preserve 
their health to a fair degree, but when the tumors multiply 
rapidly, and especially when they begin to suppurate, the general 
health fails; indigestion, diarrhoea, and marasmus supervene. 

Mycosis may invade any and every portion of the integument, 
but the lesions are more frequently observed on the trunk, 
and on the proximal and inner portions of the limbs, than on 
the face and extremities. 

Mycosis is an essentially chronic disease, taking usually years 
to run its course of erythematous and papular development, 
retrogression, relapse, hypertrophy, ulceration, etc. Excep- 
tions occur, and the hypertrophic and rapidly ulcerating lesions 
may form the first stage in its development. 

Pathologically, granuloma has by some been supposed to be 
allied to sarcoma. The prefungoidal or premycosic stage, 
however, together with the whole clinical course of the disease, 
and to a less extent the histological data place it as a distinct 
affection. Histological examination shows thinning of the rete 
which becomes a mere wavy line, the papillae are squeezed out 
by the pressure of the growth below making them shorter and 
broader, and the corium is infiltrated with small, round, lym- 
phoid cells. 

The disease usually terminates fatally, and even in those 
cases in which a return to health has been observed, the patients 
do not seem to have been kept under observation long enough 
to make it certain that a permanent cure had been obtained. 
Ordinarily the patient succumbs to some accidental complic- 
ation, or to cachexia, or more frequently with the symptoms 
of leucocythaemia. 

The treatment consists in the administration of tonics and 
nutritives, together with the continued administration of arsenic, 
hypodermically when possible. Of late the X-ray treatment 
has been employed with remarkably good effect in a few 
cases. 



LEPRA. 



335 



LEPRA. 

Lepra, or leprosy, is an endemic, chronic, malignant, con- 
stitutional disease, due to the invasion of the bacillus leprae, 
characterized by alterations in the cutaneous, nerve, and bone 
structures, resulting in anaesthesia, ulceration, necrosis, general 




Fig. 57. — Macular leprosy. (Leloir.) 

atrophy, and deformity. It is a constitutional affection and 
involves the whole organism most profoundly. Its invasion 
is slow and insidious. Premonitory symptoms of malaise, 
mental depression, languor, sleepiness, loss of appetite, nausea, 
chills, repeated attacks of fever, general debility, nervous pros- 
tration, and pains in the bones are usually present and may 



336 DISEASES OF THE SKIN. 

last for weeks, months, or years, without other symptoms. 
Sooner or later, however, the more characteristic features of 
the disease, the bullous, macular, pigmentary, or tubercular 
skin lesions, make their appearance. These may appear sepa- 
rately, successively, or together. Sometimes the skin lesions 
are prominent symptoms of the disease; at other times they 
are subordinate. Other organs of the body, as the nerves, are 
also affected. 

Two forms of leprosy are recognized, the tubercular and the 
anaesthetic. No absolute line, however, separates them; they 
often appear simultaneously upon different parts of the body, 
and one may pass into the other. The tubercular variety is 
characterized by the formation of masses of infiltration and 
tubercles. Other lesions are also found. An eruption of pem- 
phigus-like blebs, showing themselves irregularly for some 
time before the appearance of other lesions, is one of the earliest 
symptoms. It is said that these more frequently precede the 
macular variety of leprosy than the tubercular. Macules now 
make their appearance as smooth, shining, erythematous patches, 
sharply defined, infiltrated, not commonly raised above the 
level of the skin, yellowish or reddish in color, and growing 
dusky yellow and brownish as they grow older. Sometimes 
they are paler, and look like a piece of cut raw bacon set into 
the skin. 

They are commonly surrounded by a pinkish or lilac border 
of small blood-vessels. The sensibility of the skin is altered 
from the beginning, the patches being at first hyperaesthetic 
and later anaesthetic. They may appear anywhere on the 
body, but most commonly upon the trunk and extensor surfaces 
of the extremities. Sometimes they are present in such numbers 
as to involve a considerable area of the body. They may dis- 
appear and reappear from time to time, or they may remain as 
permanent lesions, in which case they increase in size.* 

Sooner or later the disease shows itself in the form of variously - 

*The plates representing macular and tubercular leprosy, here given, are from 
Norwegian cases, and have been reproduced from Leloir's monograph on 
Leprosy. 



LEPRA. 



337 



shaped and sized nodules and tubercles, situated in the skin 
and subcutaneous tissues, which may develop into roundish, 
irregularly-shaped prominences and elevated masses, from 
cherry to walnut size, or larger, conspicuous and prominent, 




Fig. 58. — Tubercular leprosy — Early stage. (Leloir.) 



or slightly raised, and having a yellowish, brownish, or bronze 
color. They are more or less painful when pressed upon. 
They are usually found upon the face; and chiefly the forehead, 
eyebrows, cheeks, nose, lips, chin, and ears are apt to be invaded, 
giving rise to deformity, often of a hideous character. Later, 
the mucous membrane of the mouth, pharynx, epiglottis, larynx, 



338 DISEASES OF THE SKIN. 

and nares are attacked; the eye also suffers. Besides the face, 
other portions of the body, notably the trunk, buttocks, arms 
and legs, fingers and toes, are invaded. The course of the 
tubercle varies; it may last a long time without change, or it 
may soften or ulcerate at once, or it may be absorbed. Ulcer- 
ation is apt to occur about the fingers and toes, the ulcers being 
covered with adherent brownish crusts. 

The anaesthetic variety of leprosy may occur in conjunction 
with the tubercular variety or alone, in which case it is character- 
ized by the presence of a number of symptoms in addition to the 
anaesthesia. Blebs are apt to appear, first coming out in an 
irregular manner, from time to time, and being followed by 
pigmentation, and, after a longer or shorter time, by anaesthesia 
about the seat of the former lesions. In other cases, macules, 
like those which sometimes precede the tubercular form, come 
first. Hyperaesthesia of the skin sometimes occurs, with pains 
and burning sensations, followed by anaesthesia affecting a 
limited portion or the greater part of the surface. Later the 
skin becomes atrophic, dry, yellowish, or brownish in color, 
and more or less wrinkled. 

Following this alteration in the structure of the skin, the 
subcutaneous tissues and muscles undergo atrophy, giving 
rise to deformity, especially of the fingers and toes; the hairs and 
nails become altered in structure or are shed; the hands and 
feet become greatly mutilated; the fingers and toes bent, crooked 
and contracted. Sooner or later the bones are attacked, causing 
destruction of the joints and of the bones themselves; the skin 
over the joints becomes excoriated and ulcerated; the ends 
of the bones undergo disintegration, and the phalanges, finally, 
either become absorbed or drop of. Even the hands and feet 
may gradually be lost; the extremities become more or less 
completely anaesthetic and are greatly wasted, at times to half 
their former size. 

The disease does not usually give rise to much pain or suffering. 
Death occurs more commonly after some years, by diarrhoea 
or exhaustion. 



LEPRA. 



339 



The causes of leprosy still remain obscure. It is endemic 
in Africa, along the shores of the Mediterranean, and of the 
Atlantic and Indian Oceans, as well as in the interior of the 
country; also in Asia Minor, Arabia, Persia, India, China, 
Japan, Kamtschatka, the various islands of the Pacific Ocean, 




Fig. 59. — Tubercular leprosy — Late stage, with ulceration. (Leloir.) 



and Australia. In Europe, it is found in Norway, Southern 
Spain, Sicily, Greece, and Southern Russia. Upon the Western 
Hemisphere, it occurs in Mexico, Central America, the Islands 
of the West Indies, along the coast of South America, and especi- 
ally in Brazil; it also exists in Iceland. There are old centers 
of the disease in Tracadie, N. B., in South Carolina, and in 



340 DISEASES OF THE SKIN. 

Louisiana. Norwegian emigrants have introduced it into 
Minnesota, but it has not spread, nor have the Chinese lepers 
in San Francisco and elsewhere conveyed this disease to natives. 
Within the past few years, cases of undoubted authenticity 
have been reported as occurring among natives of the United 
States who have never been out of the country nor come in 
contact with lepers. 

The method by which the organisms gain access to the 
system is not known. Recent observations seem to indicate 
that the mucous membrane of the nose and probably of the 
mouth also may be a not uncommon source of communication 
and infection. It is not improbable, also, that entrance may take 
place through some abrasion in the skin. The discovery of 
the bacillus leprae places beyond doubt the contagious nature 
of leprosy. Practically, however, we know so little of the cir- 
cumstances favoring the growth, propagation, and transmis- 
sion of this bacillus, and the clinical evidence is so contradictory, 
that we cannot put this affection in the same class as the conta- 
gious exanthemata, or with syphilis as regards the practical 
danger of transmission.* 

The most potent causes favoring the spread of the disease 
appear to be connected with climate, state of the soil, food, and 
habits of the people. The disease usually occurs among the 
lowest classes, but it may attack those in the most favored cir- 
cumstances. It occurs in both sexes and at any period of life. 

The diagnosis of leprosy, in countries where the disease is 
endemic, is usually easily made. The earliest premonitory 
symptoms arouse suspicion, which the appearance of the cuta- 
neous manifestations places beyond doubt. When the disease 

* There are still great differences of opinion as to the necessity of segregation. 
The views of Morrow ("Prophylaxis and Control of Leprosy in this Country," 
Trans. Am. Dermatol Assn., for 1900) are those usually held by American derm- 
atologists. The anaesthetic cases are less dangerous to a community than the 
tubercular form and seggregation less urgent. The necessity of segregation in 
locatities where the disease may occur sporadically or may be imported in the 
person of a single patient is not obvious. Unfortunately, the prejudice of the 
ignorant, not combated as energetically as it should be by physicians, has led, 
even in recent years, to scenes of revolting cruelty in the persecution and even 
hounding to death of unfortunate lepers who may have unknowingly appeared 
in our midst. 



LEPRA. 



341 



occurs sporadically, in countries where it is not endemic, it 
may, however, be mistaken for other affections. 

The macular and tubercular varieties are apt to be mistaken 
for syphilis. The lesions of leprosy, however, are larger and 
more irregular in size and distribution. The pigmentation of 
leprosy is of a peculiar yellowish or brownish tint. The lesions 
have a smooth, glazed appearance. The tubercles are apt to 
be much larger than those of syphilis, being often hazel-nut- 
or walnut-sized, and are darker in color; their course is usually 




Fig. 60. — Nerve or Anaesthetic leprosy, showing mutilation of hands. (Leloir.) 



slower than that of syphilitic tubercles. The general expression 
of the face (the usual seat of the tubercles in leprosy), is much 
changed, the features having an ugly, leonine appearance. (See 
plates.) 

Later, when the tubercles break down into ulcers, the black- 
ish, adherent crusts which cover them are seen to be less bulky 
than those observed in syphilis. With ulceration come other 



342 DISEASES OF THE SKIN. 

very marked features of the disease, as anaesthesia, distortion 
of the hands and feet, absorption of bone tissue, and atrophy, 
all unmistakably characteristic. 

The yellowish, roundish patches of macular leprosy should 
not be mistaken for vitiligo, although this may readily occur 
in the early stages of the disease. The health in vitiligo is 
generally good, and the decolorized patch of disease consists 
of simple absence of pigment, with usually a border of increased 
amount of coloring matter. The skin is normal in texture. 
In leprosy, on the other hand, the macules are infiltrated with a 
lardaceous-looking substance, of firm consistence, and are gener- 
ally anaesthetic or hyperaesthetic. 

Morphcea, which is an affection of an entirely different nature 
(see Morphcea), presents lardaceous-looking patches, some- 
what resembling those of macular leprosy. But the general 
health in morphoea is good, and the patches show normal sensi- 
bility and tend to spontaneous recovery. 

Leprosy and syringomyelia are sometimes confounded but 
they may be distinguished by the following differences: In 
syringomyelia there is disassociation of the sensory disturbances, 
integrity of the superficial muscles of the face, absence of dis- 
coloration of the skin the hair is unaffected; there are devia- 
tions of the spine. In anaesthetic leprosy there is abolition of 
tactile sense, atrophy and paresis of the superficial muscles of the 
face, thickening and nodular swelling of nerves. There are pain- 
less discolorations upon the body, zones of anaesthesia and 
thermo-anaesthesia irregularly distributed in the shape of patches, 
with sharp transitions from the affected to the normal areas. 
These spots or islets of anaesthesia are circumscribed by a red- 
dish line, a little raised and very irregular. In syringomyelia, 
on the contrary, the anaesthetic zones of thermo-anaesthesia 
occupy large areas limited by regular fines. 

Unfortunately the diagnosis between the two affections is 
made more difficult by the fact that they may exist concurrently. 

The treatment of leprosy has thus far proved very unsatis- 
factory. As in the case of most diseases refractory to treatment, 



LEPRA. 343 

the remedies and pretended cures have been exceedingly numer- 
ous, but as they have failed for the most part, they need not be 
mentioned here. The remedies now employed are valuable 
in improving the general condition of the leper. Change of 
climate and residence, usually to a temperate and bracing atmos- 
sphere, is imperative. Strict hygienic rules should be adopted, 
including exercise and bathing, with the most nourishing food. 
Quinine and strychina are important as tonics, and the usual 
alteratives may also be employed. Symptoms are to be treated 
as they arise. 

Local treatment is valuable. Baths, plain or medicated with 
iron or sulphur, are said to be of service. Of recent remedies, 
ichthyol, the oil of cashew nut, gurjun oil, and chaulmoogra 
oil, internally and in the form of inunctions, are recommended 
on good authority. The formula for the use of gurjun oil is 
as follows: 

1$. 01. gurjun, 5j (32.) 

Aquae calcis, §iij. (96.) M. 

Churn well together, to make a cream. Apply to ulcers. 

Cashew-nut oil is applied, pure or diluted with almond oil, 
to the anaesthetic patches, being rubbed in until it nearly blisters. 
One part to three of almond oil is strong enough to begin with. 
The oil of cashew nut may also be applied pure to the tubercles 
until they open, when the sores may be dressed with gurjun 
oil. Strychnia is a very valuable remedy and should be given 
alone or in conjunction with other remedies. 

The prognosis of leprosy is unfavorable. Although a few 
cures have been reported, yet up to the present time the disease 
has almost invariably, sooner or later, resulted fatally. 



344 DISEASES OF THE SKIN. 



CLASS VII. NEUROSES. 
PRURITUS. 

.Pruritus is a functional cutaneous affection manifesting itself 
solely by the presence of the sensation of itching, without structural 
alteration of the skin. 

The various forms of itching encountered in the course 
of many diseases of the skin, accompanied by organic 
changes, have been mentioned elsewhere, in connection with 
the diseases in which they occur. Pruritus, it must be re- 
membered, is a distinct affection. The first thing that occurs 
is itching, and any lesion of the skin visible later is the result of 
the scratching to which this symptom gives rise. The feeling 
varies in different cases. Sometimes the patient describes it 
as though a piece of rough flannel were in contact with the 
skin. At other times it is said to be like the crawling of insects, 
or like a tingling sensation, with the desire to scratch. It may 
be slight, or so severe as to be almost intolerable. It is most 
frequent in middle life and old age. 

The itching arouses an irresistible desire to scratch and rub, 
with the result that the surface is generally seen to be somewhat 
roughened, hyperaemic, and excoriated in a slight or marked 
degree. In other cases the external signs are slight, so that, were 
it not for the statement of the patient, the presence of any marked 
disorder might be doubted. The itching is usually intermittent, 
and is often worse at night. Pruritus rarely invades the whole 
body at one time, though various regions may in turn be attacked. 
In most cases it occurs in certain localities, and chiefly the 
trunk, scalp, genitalia, and anus. 

Pruritus vulvae must not be confounded with other itching 
affections of the female genitals. The itching may be seated in 
the labia, vagina, or clitoris, and is an exceedingly distressing 



pruritus. 345 

affection. It is more apt to occur in middle life or in old age. 
In children it is often caused by the presence of ascarides in the 
rectum and about the anus. 

Sometimes puritus vulvas is accompanied by occasional ner- 
vous sensations starting from the clitoris and neighborhood and 
radiating through the body. The sensation is not, strictly speak- 
ing, one of itching, but rather a " nervous crisis." 

Pruritus scroti is the form of genital pruritus generally met with 
in the male. It may involve this region alone, or may extend 
along the perineum to the anus. The orifice of the urethra 
may also be the seat of the disease. The sensations are usually 
intensely annoying, and cause the patient to rub and scratch 
violently. It is worse at night, and is aggravated by warmth. 
In puritus scroti the same radiating nervous impression is at 
times observed as that which occurs in P. vulvae. 

Pruritus ani occurs in both sexes, and in children as well as 
adults. The itching may be around the orifice or just within 
the rectum. In middle-aged or elderly persons it is very often 
associated with hemorrhoids. It is, if possible, more intoler- 
able than any other of the local varieties. Sometimes it is con- 
stant, but more often it comes and goes from time to time, and 
is also worse when the patient removes his clothing or at night. 

Pruritus hiemalis (winter itch, frost-itch) was first described by 
Duhring. Corlett* has also given a full account of the disease. 
It is observed, as a rule, only in adults, appearing with the first 
frosts of autumn and lasting through the winter, to disappear in 
the spring. Fine, frosty, cold weather seems to aggravate the 
disease. It is worse when the patient removes his clothing at 
night and is somewhat relieved when he becomes warm in bed. 
The itching is usually perceived on the lower extremities, the 
body and arms being rarelly attacked. 

Bath pruritus has been described by Stelwagon.f The itching 
or burning follows a bath and is aggravated if the patient goes at 
once to bed. If he dons his clothing and moves about for a 
while the itching usually diminishes. 

* Jour. Cutan. Dis., 1891, p. 41. f Phila. Med. Jour., Oct. 22, 1898. 



346 DISEASES OF THE SKIN. 

The causes of pruritus are extremely varied, and it is important 
to keep this in mind, for the cause must, in most cases, be removed 
in order to obtain a cure. It may be caused by physiological 
changes, as gestation, or by any irregularity of the menstrual 
function in young women. Occasionally, it is associated with 
hysteria, and it is sometimes met with at the climacteric period. 
Leucorrhoea is a common cause. Organic diseases of the uterus 
and ovaries are, at times, accompanied by it. Pruritus is like- 
wise met with in many cases of jaundice, and is sometimes 
a distressing symptom. Various diseases of the nervous system 
are accompanied by pruritus. Gastro-intestinal derangement, 
constipation, genito-urinary diseases, in both sexes, and, finally, 
the ingestion of certain medicines, and notably of opium, may 
give rise to the affection. It would hardly be necessary to add, 
were not the mistake so often made, that true pruritus is in no 
way caused by either vegetable or animal parasites. When 
these are present it is by accident, or the disease is not to be 
termed pruritus. 

The diagnosis of pruritus presents no difficulties. It is a 
disease of the skin, without any primary sign of alteration in 
its structure. Whatever lesions may be present are secondary, 
and the result of scratching, or of strong applications made by 
the patient. The diagnosis depends upon the patient's state- 
ment as to the subjective symptom of itching. Pruritus is most 
apt to be confounded with pediculosis, the secondary symptoms 
of the two diseases, scratch marks and excoriations, being simi- 
lar. These, however, are more marked and definite in character 
in pediculosis. The finding of lice will settle the question. They 
are to be carefully looked for in the clothing, and every case of 
so-called pruritus should be suspected to be pediculosis until 
the absence of the parasite is demonstrated. 

The treatment of pruritus is a matter demanding careful con- 
sideration and study in each individual case. A successful 
result will, in most cases, only be attained by recognition and 
removal of the cause. Constitutional and local remedies are 
both demanded. The internal remedies are to be directed 



pruritus. 347 

against the cause, whatever the nature of this may prove. If 
constipation exists, the bowels are to be suitably regulated, sa- 
lines being usually preferable. If there is flatulence or dyspep- 
sia of any kind, such a diet is to be prescribed as shall overcome 
the digestive difficulty, and coarse, irritating, and indigestible 
foods are, in all cases, to be avoided. Exercise and fresh air 
are beneficial. A sojourn at some mineral springs may at times 
be recommended, where a course of aperient waters, may be 
taken. In many cases, close attention to these details will be 
followed by the most gratifying results. 

As regards drugs, the usual tonic and alterative medicines are 
to be employed. Irregular menstruation must be treated by the 
judicious use of iron or other remedies, cod-liver oil, etc. Quinia 
and strychnia are sometimes of use. Recourse may be had to 
bromide of potassium and chloral, alone or together, in order 
to subdue general nervous symptoms. Morphia should in no 
case be used, as it tends to aggravate the itching. 

Schamberg recommends moderate to full doses of carbolic 
acid. General galvanization, static insulation, and the applica- 
tion of static electricity by the roller electrode down the spine 
furnish relief in occasional instances. (Stelwagon). 

External treatment affords great relief, and is to be used in all 
cases. Cold and hot douches, used alternately, or hot water, 
applied as hot as it can be borne, or plain vapor baths are often 
useful. Medicated baths, containing three to six ounces (96.- 
192.) of bicarbonate of sodium, or two to four ounces (64.-128.) 
of carbonate of potassium or borax, to thirty gallons (60 liters) of 
water, will at times afford relief. Besnier recommends starch 
baths and sponging the whole body with a mixture of aromatic 
vinegar, two hundred and fifty parts, carbolic acid, five parts, 
after which, powder the surface with ninety parts of starch and 
ten parts salicylate of bismuth or salicylic acid. Sulphuret of 
potassium and sulphur-vapor baths are sometimes used with suc- 
cess. Inunctions with a bland oil, as almond oil, may be prac- 
ticed after these baths. 

Lotions of various kinds are the most generally useful applic- 



348 DISEASES OF THE SKIN. 

ations in pruritus, and those containing carbolic acid are, by 
far, the most generally efficient. Carbolic acid, in fact, is worth 
all the other remedies put together as an anti-pruritic, and should 
always be preferred, to begin with, unless some reason exists 
against its use. It may be employed in lotion, in the strength 
of five to twenty grains (0.3-1.2) to the ounce (32.) of water, with 
a little glycerine. In the following lotion the anti-pruritic effect 
of potash is added to that of carbolic acid : 

1$. Acidi carbolici, O j ( 4-) 

Potassae fusae, 5ss ( 2.) 

Aquae, f5viij. (256.) M. 

When other remedies fail, oil of peppermint or menthol may 
be applied, especially over circumscribed, itchy localities, avoid- 
ing the mucous and muco-cutaneous surfaces, where such applic- 
ations are apt to give pain. Cyanide of potassium, fifteen to 
thirty grains (1.-2.) to the pint (480.); dilute hydrocyanic acid, 
from one to four drachms (4. -16.) to the pint (480.) ; chloroform; 
chloroform, a drachm (4.) to the pint (480.) of alcohol; lead- water; 
dilute ammonia water, acetic acid, or vinegar; chloral lotion, fif- 
teen to thirty grains (1.-2.) to the ounce (32.) of water, are all 
serviceable remedies, which may be tried singly or in succession 
in troublesome cases. "Liquor picis alkalinus," an alkaline 
solution of tar, the formula of which is given under eczema, 
a most valuable remedy; also "Liquor carbonis detergens." 
They should be used at first in the strength of two or more 
drachms (4.) to the pint (480.) of water, gradually increasing. 

In some localized forms of the disease ointments are to be used 
in preference to lotions; the following is a good one: 

1^. Acidi carbolici, gr. x-xv (0.6 to 1.) 

Ung. zinci oxidi, OJ- (32. ) M. 

The following is recommended in pruritus vulvae (though oint- 
ments should rarely be used in this form of pruritus): 

1$. Hydrarg. chlor. mite, 

Ext. belladonnas, . . . . .aa 5j ( 4-.) 

Ung. aquae rosae, §j. (30.) M. 



pruritus. 349 

The following is a good ointment, but not to be used on 
abraded surfaces, and only with caution on the muco-cutaneous 
surfaces : 

1$. Cainphorse, 

Chloralis hydratis, aa oj (4. ) 

Ung. aquae rosae, 5j- (32.) M. 

The camphor and chloral are to be rubbed together until 
fluid, and then added to the ointment. The mixture may also 
be used as a lotion with glycerine and water. 

In pruritus of the female genital organs, water as hot as can be 
borne, sponged upon the parts, forms an admirable anaesthetic, 
and should be used in all cases, whatever other treatment is 
added. Sponging with hot water may be followed by the applic- 
ation of one of the following lotions: Carbolic lotion as given 
above; sulphurous acid, or, solution of alum in barley water. 
A lotion containing a drachm (4.) of the sulphite of sodium, 
four drachms (16.) of water and an ounce (30.) of glycerine 
may be painted on. Sometimes emollient poultices, particularly 
a poultice of freshly-made almond meal, which evolves a small 
quantity of hydrocyanic acid, will be found very soothing. Such 
poultices should always be sprinkled with boric acid. 

Injections of sulphate of zinc, five to ten grains (.3-. 6) to the ounce 
(30.) of water, used on alternate days with similar injections of bi- 
chloride of mercury, 1 to 2000, while the external genitals are 
bathed once or twice daily with one of Eichoff's corrosive sub- 
limate soaps, form together a useful adjuvant to any treatment 
wiiich may be employed. 

When the affection is marked by "nervous crises," starting 
from the clitoris and radiating through the body "like a shock," 
as patients describe it, a little finely pow T dered cocaine dusted 
over the clitoris and neighboring parts will give instant though 
only temporary relief. The following formula may be employed : 

1^. Pulv. cocaine muriat., 5j (4-) 

Pulv. acid, boric, 3iij- (12.) M. 

Pruritus ani is usually connected with congestion and enlarge- 



35° DISEASES OF THE SKIN. 

merit of the haemorrhoidal veins. The bowels should be kept 
open and the following injection should be used after each stool: 

1$. Pulv. zinci sulphat., 

Pulv. aluminis, aa gr. xv. (i.) M. 

Heat in an earthen vessel until all the water of crystalliza- 
tion is driven out. Then divide into eight powders. Dissolve 
one in an ounce (32.) of water for each injection. 

The injection of hot (saturated) solutions of boric acid in 
water before relieving the bowels, or perhaps, even better, the 
use of enemata containing carbolic acid, ten to fifteen grains 
.6-1.) to the ounce, are beneficial. 

Pruritus ani is generally best treated by means of ointments. 
One of the best of these is an ointment containing two drachms 
(8.) of tar to the ounce (30.) of cold cream. Another, composed 
of equal parts of belladonna and mercurial ointments, is to be 
applied on a pledget of lint. A solution in the strength of 12 to 
25 per cent, of carbolic acid in oil of sweet almonds, is a more 
agreeable application than those mentioned, and I think just 
as efficacious. 

Penciling with oil of peppermint, pure or with an equal pro- 
portion of glycerine, may do in mild cases, where the patient 
does not scratch and tear the parts, but it cannot be employed 
where there are abrasions or fissures of the muco-cutaneous 
surface. Eichoff's menthol soap is also useful. Cocaine in ten 
per cent, solution gives temporary but complete relief. % The 
application of any of these remedies should be preceded by 
sponging with very hot water. 

In pruritus scroti the following prescription will be found use- 
ful: 

1$. Bismuthi subnitratis, oij ( 8.) 

Acidi hydrocyanici, dU., f 3ij ( 8.) 

Mist, amygdalae, fgiv. (128.) M. 

In the pruritus of jaundice, mercurial ointment is said to be of 
value, also lotions of chloroform, one drachm (4.) to five (20.) 
of glycerine, cyanide of potassium, one drachm (4.) to the pint 



PRURITUS. 351 

(480.) of water, and acetic acid baths or lotions in the strength 
of half a pint (240.) of the acid, to three gallons (four liters) of 
water, or about two quarts of strong vinegar to an ordinary thirty- 
gallon (sixty liter) bath. 

I cannot leave the discussion of this important subject, the 
treatment of one of the most painful and annoying of all diseases 
of the skin without adding some general remarks, the result of my 
experience, not only in the treatment of pruritus, but also of 
other skin diseases of a chronic and stubborn nature. In all 
of these much depends upon the care and thoroughness with 
which the physician's directions regarding diet and regimen are 
carried out. To ensure this the directions themselves must be 
full and expilcit. The patient's case must be made the sub- 
ject of careful study; the exact diet suitable to the individual 
must be decided upon and enforced in such terms as to leave no 
doubt in the patient's mind as to the importance of every detail. 
Generalities in the way of directions, with a careless indication, 
in broad terms, of the articles of diet to be used and avoided, are 
not likely to produce a serious impression on the patient's mind, 
and the failure to amend is followed by a general despondency 
and distrust of all remedies. 

The prognosis of pruritus should be guarded. The disorder, 
as a rule, is obstinate, often extremely so. The prognosis 
depends largely upon the cause and our ability to remove it. 
The patient must be encouraged to persevere with and thoroughly 
carry out the treatment. In grave cases melancholic symptoms 
may be present. Occurring in the aged, the prospect of ultimate 
cure is poor. 

In middle-aged females, pruritus vulvas is the commonest 
form met with; a most distressing malady, and one which calls 
for every possible effort to ameliorate it on the part of the phys- 
ician. 

Anesthesia, strictly speaking belongs to the domain of the neurologist. It 
may be central or peripheral in origin, local or general, although it is usually 
limited to certain areas. Numbness may exist, or the sense of feeling may 
be entirely lost. The sense of touch may also be partially or completely lost 



352 DISEASES OF THE SKIN. 

Sometimes acute pain in the part may coexist. Anaesthesia occurs in such 
diseases as syphilis, scleroderma and leprosy. Hysterical anaesthesia is not 
uncommon. 

Hyperesthesia, like anaesthesia, is usually met with in general nervous af- 
fections, hysteria, etc., and is not ordinarily connected with any disease of 
the skin. 

Dermatalgia (sometimes called rheumatism of the skin) is characterized 
by pain in the skin independently of any structural lesion. Burning, sting- 
ing, pricking, shooting pains, aggravated by night, by movement, etc., are 
experienced It is seated more commonly in the hairy parts of the skin. 

Erythromelalgia, first described by Weir Mitchell, is characterized by 
burning, aching and neuralgic pain, with redness of the extremities. It may 
involve one or all the toes or fingers. The pain is aggravated when the part 
is warm. It may present an almost phlegmonous appearance. According 
to Spiller and Mitchell* it is in some cases due to peripheral neuritis. Mod- 
ified Raynaud's disease sometimes coexists. 

*See Spiller and Mitchell, Am. J. Med. Sci., 1899, p. 1. 



DISEASES OF THE NAILS. 353 



CLASS VIII. DISEASES OF THE APPENDAGES. 
1. DISEASES OF THE NAILS.* 

The diseases of the nails to be here considered are hyper- 
trophy, atrophy, trial formations, deformities, separation 0} the 
nail plate, discoloration, parasitic diseases, onychia and paro- 
nychia. 

Hypertrophy. Increase in the substance of the nail may take 
place simply as a thickening, or as a general enlargement of the 
whole substance of the nail. Both are known as onychauxis. 
In the first form the nail is unshapely, thick, opaque, glossy on 
the surface, or spherically curved, and of a grayish- white color, 
has a massive feel, is heavy, and so hard that it can only be cut 
by a saw. When the change affects the whole nail it often shows, 
at its free border, a tendency to curve downward. In the second 
form of hypertrophy, should the nail increase in a lateral direc- 
tion, the effect is felt in the soft parts; should it increase longitu- 
dinally, it may grow several inches in length, curving and twist- 
ing grotesquely, and forming the deformity known as onycho- 
gryphosis. Onychogryphotic nails have a dirty yellow, brown- 
ish, or grayish color, with a shining lustre, and are marked with 
longitudinal and also transverse ribs, with occasional horny 
plates. The under surface is usually brownish, with an irregu- 
lar, flaky exterior interrupted by smaller or larger cavities, 
and crossed here and there by transverse ridge-like projections. 
The anterior portion of the matrix, and the entire area of the nail- 
bed, are shown by microscopical examination to be in a chronic 
state of irritation. 

Onychauxis may be congenital or acquired. At birth the nail 
may be only slightly developed in excess of its normal average, 

* For a full account of the diseases of the nails see Heller, Die Krankheiten der 
Nagel, Berlin, 1901. Also C. J. White, Clinical Study of 485 Cases, Boston Med. 
and Surg. Jour., Nov. 13. 1902. 

23 



354 



DISEASES OF THE SKIN. 



but it grows with a greater relative rapidity. The various dis- 
eases associated with papillary hypertrophy (e.g., ichthyosis) 
seem to favor the development of this inborn tendency in the 
nail. More commonly onychauxis is acquired and may be traced 
to some traumatic cause — to neglect, to the extension of morbid 
inflammatory processes of the corium and the connective tissue 
of the cutis to the matrix of the nail (e. g., psoriasis, chronic ec- 






Fig. 61. — Hypertrophy of Nail. 



zema, lichen ruber, lepra, elephantiasis, etc.). Some pre- 
disposition to onychauxis must, however, exist in these cases, 
as not every case of these diseases shows hypertrophy of 
the nail (some even show atrophy), and as, furthermore, the 
nails are, at times, affected when the skin disease does not exist 
in contiguous parts. 

Symptomatic hypertrophy of the nails sometimes occurs in 



DISEASES OF THE XAILS. 355 

neuropathic affections of a degenerative or irritative character, 
most frequently in spontaneous neuritis, neuralgia, chronic 
myelitis, traumatic lesions of mixed nerve trunks (" glossy skin"), 
etc. The same alteration of the nails may occur after various 
chronic diseases, as articular rheumatism, affections of the bones, 
or ankylosis. Partial hypertrophy may occur after various ulcera- 
tive processes in the nail-bed, in which the remaining part of the 
matrix appears to attempt to make up the loss. 

The effect of hypertrophy of the nails is not only cosmetic 
deformity, but absolute loss of tactile sense to a greater or less 
degree. The person is unable to execute delicate or fine work. 
Fortunately, onychogryphosis of the fingers is rare, and even 
onchyauxis to a marked degree is uncommon. When the toes 
are affected, walking may be more or less interfered with, and in 
advanced cases may become altogether impossible. Lateral 
hypertrophy may produce inflammation and ulceration in the 
surrounding soft tissues (ingrown toe-nail). 

The prognosis in hypertrophy of the nail depends upon the 
chance of removing the cause. Of course, the hypertrophied nail 
can in no wise be altered, but if the eczema, psoriasis, etc., can 
be cured, there is good reason to hope that a healthy nail may be 
developed from the matrix. In the case of such diseases as 
lepra or elephantiasis, where the disease is incurable, but little 
hope can be entertained of improving the state of the nail. The 
same is true when the matrix has been altered by traumatic 
influences to an irremediable extent. 

The treatment consists in removing the cause when attainable, 
and in doing away with the hypertrophied product when this 
becomes a serious annoyance. The nail may be removed by 
means of the knife, cutting pliers, or, in extreme cases, the saw. 
Where the nail has enlarged in width, it may press upon the 
lateral furrow to a greater or less extent, and when to this is added 
pressure from a tight shoe, considerable irritation and inflamma- 
tion of the soft parts may ensue, followed in extreme cases by 
great destruction of the neighboring tissues, even involving the 
tendons and bone. 



356 DISEASES OF THE SKIN. 

With regard to the treatment by removal of the cause, if eczema, 
psoriasis, or other disease exists, this must be removed by appro- 
priate local remedies, ointments, rubber finger-stalls, etc. When 
eczema is present on the body, iron, arsenic, and other remedies 
appropriate to these affections of the skin will also be found to 
affect the nails favorably. When the disease of the matrix and 
the nail-bed is due to any form of syphilis, internal treatment 
appropriate to that disease is called for, and, in addition, the 
local application of iodoform, mercurial ointment, or solution 
of corrosive sublimate, i to 250 of water. 

When the cause is traumatic, as from an ill-fitting shoe, this 
should be remedied, or when from severe occupation, protection 
of the finger or toe by soft wax or other mechanical device. 

Atrophy of the nail, may be congenital or acquired. The 
congenital form is met with in connection with imperfectly devel- 
oped fingers and toes, the nail being cither entirely absent, 
imperfectly developed, mutilated, or coalescing with other nails. 

The acquired form of atrophy of the nail is met with as a result 
of traumatic influence, as pressure of shoes, etc., which at times 
may produce hypertrophy, and at other times atrophy. The 
nail formation may also be hindered by a knock, blow, pinch- 
ing, etc. 

"Leukopathia unguium" is a form of atrophy in which white 
spots or transverse bands occur. This may be congenital but 
is most frequently observed after fever or wasting diseases. 
Geber looks upon white spots on the nails as a sign of insuffi- 
cient cornification of the nail cells, traceable to mechanical in- 
fluences.* 

Thermic and chemical sources of irritation are not uncom- 
mon causes of atrophy of the nail, as are also inflammations 
associated with suppuration and ulcerative processes. 

Among the constitutional causes of retarded nail growth are 
febrile conditions and chronic wasting conditions of the general 
organism. Typhoid fever on the one hand, and tuberculosis 
on the other, may be mentioned as typical causes. Those cuta- 

*See Heidingsfeld, Leucopathia Unguium, Jour. Cut. Dis., 1900, p. 490. 



DISEASES OF THE NAILS. 357 

neous diseases and nervous affections which produce hyperplasia 
of the nails, such as ichthyosis or ataxia, may, under other con- 
ditions, give rise to precisely the opposite effect. 

The imperfectly developed nail is whitish-gray, lustreless, 
thin, and delicate, giving the impression of a thickened mem- 
brane, possessing but slight hardness, readily broken and flex- 
ible. At times the substance is so friable that it exfoliates longit- 
udinally and fractures through its thickness, thereby rendering 
the nail uneven. 

The treatment includes, first, frequent trimming and cover- 
ing of the affected nail with a protective layer of wax. The 
removal of the etiological factor is next to be attended to. The 
main point is to keep away any possible injurious influences, to 
cure, if possible, any accompanying skin diseases, dyscrasic or 
nervous affections, inflammations and ulcerative processes, and 
to support the strength of the patient when impaired nutrition 
may be the cause. When the defective nail formation is due 
to some incurable disease, it is, of course, impossible to expect 
a change for the better. Geber thinks that equable pressure 
exerted by strips of adhesive plaster upon a wax nail fastened to 
the nail-bed will hasten the regeneration of the nail. 

Malformation of the nail plate is a result of disturbed function 
of the matrix. The latter may be the result of nerve disturbance 
(paralysis), of injury, malformation of the lateral furrow, inflam- 
mation of the underlying connective tissue, periosteum, bone, etc. 

Nails suffering from deformity may be long, short, narrowed, 
or curved one way or another, occasionally pointed. A not very 
uncommon form is the so-called "spoon nail" in which one or 
more of the nails are hollowed into a concavity. I have reported 
a case where the nails were curved or rolled in at the edges so 
as to present a semi-cylindrical figure., and so shrunken that they 
occupied only about one-half the normal width of the nail-bed. 
The case was that of an infant suffering from hereditary syphilis. 
The deformed nails were gradually replaced by normal ones as 
the infant regained health under treatment. . 

Sometimes deformity of the nails may be hereditary. As the 



358 DISEASES OF THE SKIN. 

cause can rarely be removed, the affection is usually irremediable. 
Fortunately, it is rarely more than a mere disfigurement. 

Degeneration of the nail may occur as a result of faulty nutrition, 
but is also met with following chronic inflammatory processes 
(paronychia sicca) of the matrix. The nail may be thick or thin, 
or more frequently fibrous, and spread with an irregular detach- 
ment of particles. The color changes to a grayish- white or dirty 
yellowish-gray. Aside from disfigurement, these nails are very 
troublesome, as they are continually breaking and splitting, and 
occasionally denude the nail-bed. Removal of the cause, when 
this can be ascertained, and protection by the wax nail covering 
and bandage, may be recommended when practicable. 

Separation of the nail plate occasionally takes place in one 
or more nails; a grayish strip of coloration appears along each 
side of the nail and gradually spreads toward the median line 
until the whole nail plate is invaded. This is then seen to be 
raised above the surface of the subungual structures, remaining 
united to the matrix only at its edges and root. 

The nail plate thus elevated above the underlying structures 
may be moved about slightly without causing pain. It grows 
as usual, and its structure remains unchanged excepting as to 
its ashen-gray color. Occasionally, white achromic patches are 
seen scattered over the surface. 

Such cases are very rare. Bazin considers them due to eczema. 
One case under his care was cured by applications of tincture 
of iodine. 

Discoloration of the nail is only worthy of a passing notice. 
The changes to purple, to chalky- white, to yellow, etc., in various 
diseases, are probably due to only the translucency of the nail, 
showing the congestion or discoloration of the tissues beneath. 

Traumatic and chemical injuries may affect the texture of 
the nail from a distance. Thus, workers in acids, etc., and those 
who use peculiar tools, may have alterations in the nail following 
long-continued action at a distance. The animal and vegetable 
parasites may also affect the texture of the nail. 

Parasitic Diseases of the Nail. — The itch insect, "sarcoptes 



DISEASES OF THE NAILS. 359 

scabiei, " may give rise to various changes in the nail. Boeck 
states that the ova and excrement of the sarcoptes are to be 
found in the degenerated nail substance. Bergh has shown that 
the deviations in the nail due to the sarcoptes are brought about 
on the one hand by affection of the nail-bed and matrix, and on 
the other by implication of the nail substance. 

Various tropical flies, which lay their eggs under the nails, 
may cause disease, but none of these is so harmful as the sand- 
flea {Ptil ex penetrans), which causes at first violent pain and, 
following this, paronychia. 

Vegetable parasitic diseases of the nails are less uncommon 
than those caused by animal parasites. The disease is more 
apt to spread from the adjacent skin than it is to be implanted 
directly under the nail. The onychomycoses are, so far as yet 
known, of only two kinds, that due to favus, and ring-worm. 
The clinical appearance is not very different, and will be des- 
cribed once for both. Favus is the more rare. The nail affected 
shows signs of change at an early date after the implantation of 
the fungus, becoming brittle, frayed out, and intersected by 
furrows, and presenting a discolored, opaque, grayish or yel- 
lowish-white appearance, and is more or less lifted up. When 
the process has continued for a considerable time the alternation 
extends to the entire nail, and the matrix being implicated, 
changes in growth are perceptible. The nail becomes claw-like, 
thickened, flakes off even on the surface, and being detached 
here and there, and acquiring a faded, dirty yellow color, becomes 
exceedingly disfiguring. Rare cases of favus infiltration of the 
nail show the peculiar sulphur-yellow crusts or scutulate depres- 
sions; but the worm-eaten appearance produced by numerous 
other affections must not be mistaken for this, and, in fact, apart 
from the actual discovery of the fungus, an exact diagnosis can- 
not often be made. In this country parasitic disease of the nail 
is excessively rare. 

Longitudinal or transverse sections through a nail changed by 
the infiltration of fungus show disintegration of the substance, 
and by treatment with glycerine, convoluted threads of myce- 



360 DISEASES OF THE SKIN. 

Hum and conidia mixed with cornified epithelium can be observed 
under the microscope. 

The treatment consists in scraping the nail very thin and apply- 
ing a parasiticide. Strong acetic acid is the best, as it softens 
and penetrates the horny tissues. 

Onychia and paronychia are the names given to certain 
inflammatory conditions occurring about the base of the nail 
plate in the first instance or about the sides of the nail in the 
latter. The affection in both cases is usually due to traumatism, 
pressure of the nail or the accidental introduction of pus organ- 
isms. In paronychia the invasion of the staphylococcus may 
penetrate further into the tissues and give rise to whitlow or felon. 
I have described a peculiar herpetiform onychia in which the for- 
mation of vesicles or vesico-pustules took place at the root and 
sides of several nails, accompanied by severe pain and subse- 
quent alterations in the nail structures. 

The treatment of onychia and paronychia consists in the 
removal of the cause (pressure from the nails, ill-fitting shoes, 
etc.), careful disinfection of the parts by soaking in hot solutions 
of bichloride of mercury (1-2000) and subsequent dressing with 
ichthyol and lead-water or other sedatives. 

2. DISEASES OF THE HAIR AND HAIR FOLLICLES. 
HYPERTRICHOSIS. 

Hypertrichosis or excessive growth of hair may be congenital 
or acquired. Congenital hypertrichosis may be partial or 
general. The partial hypertrichoses are generally pigmented 
naevi. (See Figs. 62, 63 and also under Naevus pigmentosis.) 
Generalized or universal hypertrichosis is an abnormal de- 
velopment of the hair in all those regions in which it nor- 
mally grows, either as adult hair or lanugo. Those parts of 
the body, as the palms and soles, which are normally hairless 
never take part in the overgrowth of generalized hypertrichosis. 

Acquired hypertrichosis is usually localized, although a few 
cases are on record where it has been nearly universally distributed. 
Hairs growing on the face, arms and other exposed parts in 



HYPERTRICHOSIS. 



;6i 



women are those for which relief is commonly sought. The 
other forms of the disease are rather medical curiosities. 

Many females experience an extra growth during youth 
or adult age, which in certain cases may assume excessive pro- 
portions; usually the upper lip is the part most markedly affected, 




Fig. 62. 

Hypertrichosis Localis. 



(After Eckert.) : 



but the overgrowth may also occur on the chin and cheeks, form- 
ing a genuine beard, sometimes of very considerable proportion, 
as in the case reported by Duhring, of which a picture is here 
appended.f (Archives oj Dermatology, April, 1877.) 

*Ecker. Abnorm. Behaarung des Menschen. Braunschweig, 1878. 

t The woman, who was married and twenty-three years old, said that the hair 
had begun to grow in childhood, and had gradually increased year by year, grow- 
ing more vigorously as the period of puberty approached. The hair of the scalp, 
at the [age of twelve, was quite long, extending to the hips, and by no means 



3 62 



DISEASES OF THE SKIN. 



It has been asserted that this form of hypertrichosis occur- 
ring in women is closely related to disturbances of the genital 




Fig. 64. — Hypertrichosis (Bearded Woman. Dr. Duhring's case.) 

functions and also that it is not infrequently connected with 
strong sexual inclination. With regard to the latter point, 

thick. Menstruation began at the age of fourteen and has been normal. The 
establishment of menstruation did not seem to increase particularly the over- 
growth of hair in the beard. Hair first manifested itself now in the axilla, on the 
pubes, and on certain regions of the trunk and the extremities. The increase in 
the growth of the beard continued until the age of eighteen, since which time it 
had been stationary. She was married at the age of seventeen and a half, and 
had had two children, living to the age of two and four years, respectively, with- 
out showing any signs of overgrowth of hair. The hair of the scalp having fallen 
out during fever, was cut, and at the time of examination was rather scanty. 
The hairs of the moustache were about one-half inch long, of fine texture; those of 
the beard were about five inches in length, curly, thickly set, and of fine quality, 
dark brown in color. There was a diffused hairy patch, about the width of the 
hand, extending across from shoulder to shoulder on the back. There was a per- 
ceptibly excessive growth of hair down the whole back, rather sparse, starting 
from either side of the spinal column, and taking a course downward and forward 
around the sides of the thorax, covering the latter portions of the trunk. The 
vertebral column itself was almost entirely destitute of hair. The hair upon the 
axilla was no more profuse than normal, and Dr. Duhring was assured that the 
pubic hair was no more abundant than in most hirsute women. The limbs, with 
the exception of the forearm, were not remarkably hairy; the latter showed con- 
siderable growth of hair, but not very excessive. 



HYPERTRICHOSIS. 



3 6 3 



I am convinced there is rarely any relation whatever between 
the two conditions. The result of my experience is that the 
majority of cases which I have been describing occur in women 
who are not only not consciously subject to strong sexual feeling, 
but in many cases, as far as can be ascertained, are perhaps more 
than is usual, even in the case of women, devoid of those feelings. 
There is no question that in some cases there is a relationship 
between uterine and ovarian disturbances and excessive growth 
of hair on the face of females, but an examination of a large 
number of cases has brought me to the conclusion that the two 
conditions are by no means fre- 
quently dependent upon one 
another. In fact, I do not 
think that we can accurately 
state what the causes of this 
form of hypertrichosis are, 
although there is no question 
that the nerves have more or 
less direct influence, especially 
the trigeminal or fifth pair. It 
will be observed in most cases 
of overgrowth of hair upon the 
female face and chin, that the 
largest hairs appear at and 
about the points on either side 
of the chin at which the submaxillary branch of the fifth pair 
emerges from the bone. 

Hypertrichosis may occur at four different epochs in the 
life of women. It may exist at birth; it may appear between 
fourteen and sixteen years, about the period of puberty, or 
when the beard appears in men; it may occur in adult life, or 
it may not appear until the menopause. 

Hypertrichoses of the first two varieties are usually most 
abundant; to these two classes belong those well-developed 
beards of a decidedly masculine character which are most 
usually the object of public curiosity. 




Fig. 65. — Hypertrichosis Universalis 
(Julia Pastrana). (After Ecker.) 



3 6 4 



DISEASES OF THE SKIN. 



The third variety of hypertrichosis in women, that which 
occurs in the adult, is generally less profuse than in the first 
two varieties. Occasionally, however, cases have been reported 
in which adult women have developed full beards. It is said 
that this form of hypertrichosis frequently coexists with dis- 
turbances of menstruation (amenorrhcea or dysmenorrhcea). 
Occasionally pregnancy, which causes cessation of the menses 
and also marked modifications in the entire organism, brings 




Fig. 66. — Hypertrichosis (the Russian Dog-faced Man). (After Ecker.) 



with it an excessive growth of hair. Slocum (N. Y. Medical 
Record, July 10, 1875) reports a case of this kind. 

Hypertrichosis occurring at the epoch of the menopause is 
extremely common. I should even say that the majority of 
women present a slight hypertrichosis at this period. This 
form of hypertrichosis is of anthropological interest, but excepting 
when well-marked, the dermatologist is not often called upon to 
treat it as a pathological condition. I think that this form of 
hypertrichosis is not due directly to any change in the sexual 
or reproductive organs themselves, but is the effect of the peculiar 
nervous changes which accompany in the majority of cases 



HYPERTRICHOSIS. 365 

this period of life in women. Brocq says that when excessive 
hypertrichosis occurs in such cases women are apt to become 
nervous, impressionable, melancholy; sometimes the woman 
at this period becomes morbidly afraid of venturing out-of- 
doors ; she imagines that every one is watching her and examining 
the extraordinary growth of hair; she even thinks that she is 
followed in the street at times; and the woman who is under 'his 
form of hallucination or morbid sensitiveness becomes a torment 
to herself and a misery to those around her. The moustache 
and beard, as it is called, becomes in these women what the 
French call an idee fixe, which may lead to insanity. 

Pathological Hypertrichosis. The hypertrichoses which form 
this group are distinguished from all other forms by the fact 
that they occur as the result of a detrimental lesion. The seat 
of the original lesion as well as its nature may vary greatly; 
sometimes it is a cutaneous irritation provoked by some local 
irritative application; at other times the cause is a nervous 
lesion usually of traumatic character. Hebra describes a case 
in which the employment of mercurial ointment brought out 
a growth of hair, and numerous similar cases have been reported 
by various authors, and, in fact, such growths may be observed 
by any practitioner of large experience. It is not unusual to 
meet with individuals of either sex who have small bunches of 
hair growing from a flat pigmentary spot or from a pigmentary 
mole or wart. These are the pigmentary naevi of which illustra- 
tions are given here and which may occur on almost any part 
of the body, and which are described in most works on diseases 
of the skin. 

Hairy Growths Produced by other Cutaneous Disorders. 
The hypertrichoses of this kind are neither frequent nor well 
marked, nevertheless they are met with from time to time. 
Excessive growths of hair sometimes occur on the surface which 
has been occupied by the lesions of prurigo. Keloid growths 
may also favor the growth of hair. 

Hypertrichoses Resulting from Lesions oj the Nerves. Hy- 
pertrichoses of this kind most frequently occur after traumatic 



366 . DISEASES OF THE SKIN. 

lesions of the nerves. Mitchell and Keen have reported cases 
of this character occurring after gun-shot wounds. In all 
these cases, which resemble each other very closely in their 
origin and mode of occurrence, the overgrowth of hair always 
followed a neuritis. There is a hypernutrition of the elements 
of the region involved, especially those of the skin, the epidermis, 
pigmentary granules, sebaceous and sudoriferous glands, and 
hairs all being involved. 

Hypertrichosis Caused by Lesions of Central Nervous System. 
Spontaneous or traumatic lesions of the cord may sometimes 
be the cause of hairy overgrowths. 

Treatment is only called for in those cases of hypertrichosis 
when a cosmetic effect is required. Here in many cases depila- 
tories may be employed. The following are those generally 
recommended. Baetge uses a paste of sulphite of calcium 
made by passing sulphuretted hydrogen through milk of lime. 
This, to be effectual, must be used fresh. 

Another formula is the following: 

1$. Pulv. orpiment, 

Pulv. lithargyri, aa ovijss (30.) 

Hydrarg. vivi, 5xv (60.) 

Pulv. amyli, ovijss (30.) M. 

The following formula is said to be that in vogue among the 
Turks: 

ty. Arsenici trisulphureti, oij (8. ) 

Calcis vivi, oij (64. ) 

Amyli, 3ij ad. v (8.-20.) 

Aquae bulliente, q. s. M. 

This is also made into a paste and applied with a spatula. 
After remaining in contact with the skin five or ten minutes, 
or until a slight tingling sensation is felt, the paste is removed, 
the skin washed, and the surface is powdered with starch. I 
may say that I have had little experience with these preparations. 

A great number of similar formulae may be found in the 
standard works upon diseases of the skin, to which the inquirer 



HYPERTRICHOSIS. 367 

may be referred. None of these, however, can do more than 
destroy the hair down to the level of the skin or a short distance 
into its follicle. The hair begins to grow again at once, and I 
cannot see any advantage to be gained by depilatories over that 
obtained by simple shaving. Moreover, the skin itself suffers 
from these caustic applications, and any sharp-sighted observer 
can immediately detect the artifice. 

The application of peroxide of hydrogen bleaches the hair, 
and this procedure is worth trial in the case of brunettes having 
an abundant growth of downy black hair upon the face. 

The treatment of hypertrichosis is only a matter of practical 
interest when the hairy growth occupies such a position as to 
make it a conspicuous deformity. Hairy moles may some- 
times be removed by the knife when favorably situated and 
not too large. Circumscribed or diffuse growths of hair, occur- 
ring chiefly about the face and in females, are best removed 
by electrolysis. In former times depilation, shaving, and the 
application of caustic depilatories formed the only modes of 
treatment, and these were highly unsatisfactory, as only in part 
removing the disfigurement, and at the same time requiring fre- 
quent repetition. In fact, depilation by means of forceps is 
said, and probably with truth, to stimulate the growth of new 
hair in the neighborhood. 

To Michel and to Hardaway, of St Louis, we are indebted 
for a safe, easy, and effectual method of removing superfluous 
hairs by electrolysis. Though electrolysis had been suggested 
at a somewhat earlier date by Piffard, as a means of destroying 
the hairs in hairy naevi, the method was first employed systematic- 
ally by Michel in trichiasis, and was adopted to general dermato- 
logical use by Hardaway, who read a paper upon the subject 
before the American Dermatological Association in 1878. 

The operation, as described by Hardaway, is performed as 
follows: A No. 13 cambric needle is attached to a convenient 
handle, see Fig. 67, which latter is connected with the negative 
wire of a galvanic battery; a moistened sponge electrode is con- 
nected with the positive pole. Under a strong lens, held in the 



368 DISEASES OF THE SKIN. 

left hand (or without this if the operator has very good eyesight), 
the patient being seated in a reclining chair, facing a good light, 
the needle is entered, as near as possible, into the hair follicle; 
after this has been accomplished, and not till then, the patient 
is told to bring the sponge (positive) electrode in contact with the 
palm of the hand. The needle is not withdrawn until a slight 
frothing is observed around the stem, showing that the electrolytic 
action has been fully developed; but to avoid shock the sponge 




Fig. 67. — Flemming's needle holder for electrolysis (about two-thirds size). 

electrode is first released by the patient, the needle being removed 
subsequently, this order being exactly the reverse of the initial 
steps.* 

The hair should always be left in situ, and not extracted before 
the needle is introduced, as it is a guide for the introduction 
of the latter, the instrument being passed in alongside of it. 
Besides this, it is an immediate guarantee of the success of the 
operation; for if the hair comes away with the very gentlest 
traction of the depilating forceps, a point always to be tested, 
at once we know that the papilla has been destroyed; but if 
force is required for its extraction, it is a sign that the follicle 
has not been properly entered. In this case the needle is rein- 
troduced, or, better, it is not removed at all, repeated attempts 
being made from time to time to withdraw the hair until finally it 
is loosened. Eight cells of a freshly- charged zinc carbon galvanic 
battery (See Fig. 68) will usually suffice, or 8 to 16 silver chloride 
cells. A greater or less number, however, may be required in one 
case or another. The strength of the current required is from \ 
to 1 \ milliamperes. The operation is a painful one, and but 
few hairs can usually be removed at a sitting. 

* Some operators make and break the current by means of the button and 
spring shown in the figure. This is more convenient but much more painful 
to the patient. 



ATROPHIA PILORUM PROPRIA. 



369 



The needle should be as fine as can be procured, even finer 
than a No. 13 cambric, if such is procurable. An expert mechani- 
cian can grind an ordinary needle down to the finest diameter. 
Some operators prefer an irido-platinum needle; others a watch- 
maker's very fine steel wire. It must be remembered that the 
larger the needle the longer it can be retained in situ, and the 
stronger the battery power the more rapidly and thoroughly 




Fig. 6S. — 20-cell constant-current battery for electrolysis. 



can the hairs be removed. But if either of these conditions 
overstep the proper limits, abscess and scars are apt to follow, 
and much unnecessary pain is caused. 

In most cases, ten to twenty per cent, of the hairs remain (or 
appear to remain, for the growth of neighboring fine hairs seems 
to be stimulated by the use of the electricity), and the ground 
must almost always be gone over once, or several times. 

ATROPHIA PILORUM PROPRIA. 

Atrophy of the hair is a general term employed to cover 
various hair changes of an atrophic or destructive character. 

Whether or not a true progressive and morbid diminution in 
bulk of the hairs takes place, it is certain that their physiological 
term of life may, under some circumstances, be diminished. 
24 



370 DISEASES OF THE SKIN. 

The hairs lose their normal condition, become dry, lustreless, 
rough, brittle, cleft, and fibrillated; they swell out and break 
off. These changes often take place as the result of morbid proc- 
esses occurring in the parts from which the hairs arise — their 
follicles, the sebaceous glands, or the cutaneous structures 
immediately adjoining. After fevers and other severe consti- 
tutional disturbances, likewise, the hair may become dry and 
lustreless, and tend to fracture and splitting. 

In addition to these conditions which affect the hairs in general, 
there are several forms of atrophic structural alteration which 
must for the present be termed idiopathic, because we cannot 
assign any cause for them. 

One of these is the well-known phenomenon known as jragil- 
itas crinium, in which the hairs become split up at their extrem- 
ities. In some persons, particularly in females with long 
hair, or men with long beards, nearly all the hairs split up in 
this way. But this splitting is probably without significance, 
and does not affect the growth of the hair. 

Duhring has reported a single case of an "undescribed form 
of atrophy of the hair of the beard,"* characterized by atrophy 
of the hair bulb and by splitting of the hair substance. To the 
naked eye the affected hairs varied in size and form, some having 
a uniform diameter several times greater than normal, while 
others throughout their length were unusually slender. The 
bulbs were in nearly all instances smaller than normal, and had 
a markedly contracted look. Not infrequently the diameter 
of the bulb and root was considerably less than that of the 
shaft. The majority of the hairs showed splitting into two, 
three, or more parts throughout their entire length. Under 
the microscope, atrophy of the bulbs and fission of the hair 
substance were the conspicuous features. In the majority 
of the specimens the bulbs were distinctly shrunken and atrophied, 
appearing as small, contracted points or knobs. The hairs, 
as a rule, began to split within the bulb. 

The cause of the disease is not known. Some observers 

*Am. Jour. Med. Sci., July, 1878 (with illustration). 



ATROPHIA PILORUM PROPRIA. 371 

have considered it due to a parasite invading the hair, while 
others have thought the swelling and bursting of the hair to be 
due to the development of gas in its tissues. 

Frequent shaving and the use of parasiticide remedies offer 
the most reasonable means of treating the disease. 

Monilethrix, moniliform or beaded hair, resembles trichor- 
rhexis nodosa excepting that the hairs break at the point of 



Fig. 69. — Monilethrix-hair showing breaks at the internodes. (Lesser.)* 



constriction. The disease usually occurs on the scalp, some- 
times over a single patch, but occasionally is found in the beard. 
The broken off hairs give the patch on the scalp somewhat the 
appearance of ring-worm. The cause of the disease and its 
pathology are unknown. Treatment in cases recorded has had 
little or no effect.! 



* Lesser, Ringelhaaren Vierteljahrreschrift f 
fSee Beatty and Scott, Brit. Jour. Derm., 181 
Cut. Dis., 1898, p. 157. (Review of recorded cases.) 



Derm. u. Syph, 1886, p. 51. 
2, p. 171. Also Gilchrist, Jour. 



372 DISEASES OF THE SKIN. 

Piedra is a nodose condition of the hairs characterized by 
minute pin-head sized, hard nodules situated on or around the 
hair shaft, in appearance somewhat suggestive of nits but much 
smaller. The hair shaft itself is not involved. It usually occurs 
in the scalp but has been observed elsewhere. With the exception 
of a very few cases the disease has only been observed in South 
America. It is due to fungus growths.* 

The treatment of fragilitas crinium, especially that form 
which shows splitting of the ends of the hair, should include 
attention to the general nutrition, and stimulation of the scalp, 
when this is affected, by the hair tonics mentioned under alopecia. 
When involving the shaft or ends, the hair should be clipped off 
just below the cleft part. Vaseline should be rubbed into the 
scalp frequently. In the beard, clipping the ends or shaving 
should be continued for some time. 

Trichorrhexis nodosa is the name given to a peculiar atrophy 
taking place at certain points in the hair and giving the appear- 
ance of nodes to the intervening parts. 

Some hairs have a conical, or fan- or brush-shaped enlarge- 
ment at the end of each, and if this occurs on many hairs, on 
the moustache, for instance, the impression is conveyed that the 
hair has been singed by a flame, and has curled up at the burned 
ends. The hairs thus affected are firmly fixed on their papillae, 
but break easily at the seat of the swellings. The stump of the 
hair which remains shows the lower half of a node as its ex- 
tremity. 

Microscopic examination shows the nodes to consist of spindle- 
shaped swellings produced by a splitting asunder of the fibres 
of the hair structure, so that the appearance presented is that 
of two besoms or birch brooms rammed end-to-end together. 
It would seem that a separation or swelling takes place in the 
body of the hair, and that this produces a lighter color in the 
hair at the nodal points, as seen by reflected light, while the split- 
ting takes place at a later stage of the disease. 

*See J uhel-Renoy, A nnales de Derm, et de Syph., 1888, p. 777. (Illustrations of 
hair and fungus.) 



ATROPHIA PILORUM PROPRIA. 373 

The part usually affected is the moustache, though the beard, 
scalp and exceptionally other parts may show it.* 

Tinea Nodosa. Under this name a peculiar nodose condition 
of the hairs of the moustache and axilla has been described. f 
To the naked eye the hair appears thickened and rough, with 
some incrusting material, and here and there nodular swellings, 
sometimes hard and glistening, and in other cases soft. Numbers 
of hairs are broken off short, with brush-like ends. Under the 
microscope the roughness and thickening are seen to be due 
partly to an irregular incrustation of granular-looking material 
around the shaft, and external to it, and partly to the swelling 
of the shaft itself by the incipient separation of the fibre cells 
of the cortex. 

These incrustations or nodules have been found to be com- 
posed of an aggregation of the zooglea-form of a species of 
bacterium. 

The so-called "red chromidrosis, " which is in reality a parasitic 
hair disease, may be mentioned here. The hairs are surrounded 
at various points with closely adherent, irregular masses of a 
grayish, red or yellowish-red color. On microscopic examination 
these are found to be composed of parasites, the exact nature of 
which is not known. 

Some writers have considered this affection under the desig- 
nation lepothrix. The hairs of the axillae are those most 
commonly affected, but I have seen the disease on the downy 
hairs of the cheek. The red color is supposed to be due to 
a micrococcus derived possibly from the sweat. J 

Shaving or cutting the hairs close, with the applications of 
parasiticides, has resulted in a cure in the cases which have 
come under my observation. 

Ingrowing Hairs. These show themselves as small bluish-whiie papules 
from pin-head to small pea-size, situated usually about the chin where the 

*Heidingsfeld, Jour. Cut. Dis., 1905, p. 246, gives resume of literature and 
bibliography. 

tCheadle and Morris, Lancet, 1879, i, p. 190 (with illustration). 

|Sonnenbetg, Monatsh. j. Prakt. Derm., vol. xxvii, 1898, p. 538. With a review 
of the subject and literature references. 



374 DISEASES OF THE SKIN. 

hair grows thickest. It usually occurs in adults who have shaved for years, 
and is apt, at first, to be taken for "black-heads" or comedo and irritated by 
pressure with watch keys and attempts to squeeze out. Careful inspection of 
the cheeks and chin (which should be made when the patient has not recently 
shaved) shows here and there the presence of " giant hairs." Slight traction 
with forceps enables these to be extracted, when a deposit of dark soft ma- 
terial which envelopes the hair over its entire extent is perceived. This is 
easily separated and the hairs are found to be blurred and indistinct in struc- 
ture and very brittle. There is no monilform appearance. The presence of 
the small, bluish-white tumors is explained by the fact that in shaving, particu- 
larly when a blunt razor is used, these diseased and fragile hairs are 
dragged upon and broken off within the hair sheath. The remainder of the 
hair still grows but the orifice of the follicle having become blocked before 
the hair reaches it, the latter continues to grow spirally like a watch spring 
within its sheath. Occasionally these ingrowing hairs are met with about 
the neck and on the border of the scalp behind. 

The spiral hair sometimes grows- round and round until it forms quite a 
tumor — a retention cyst. From such cysts hairs of several inches in length 
may sometimes be extracted. Occasionally small tufts of a dozen or more 
fine hairs are found in these cysts, which are particularly common on the 
under surface of the penis, due here, probably, to the rubbing of clothing, 
etc. Sometimes these cysts become irritated and form furuncle like inflam- 
mations, which recur until the hairs are removed. 

The treatment is removal of the diseased hair, but this must be performed 
with great care, as the slightest overtraction will cause the brittle hair to 
break within the follicle. When destruction of the hair papilla can be ac- 
complished by the electrolytic needle this should be employed as the only 
sure cure. 

CANITIES. 

Graying of the hair may be congenital or acquired. Congen- 
ital graying of the hair is quite rare. It is usually confined to 
one or several tufts or patches and in some cases has been noted 
as hereditary even through several generations. General con- 
gential gray or white hair is usually associated with albinism. 

Canities prematura may occur gradually or in tufts or patches, 
commonly showing at first over the temples, or it may occur sud- 
denly or at least with great rapidity. The causes of premature 
graying are various, severe illness, sudden shock, deterioration 
of the nervous system, or in some cases, where there is an 



CANITIES. 375 

hereditary tendency, without any appreciable cause. The hair 
may come out gray after some local disease, as alopecia areata 
or lupus erythematosus, afterwards recovering its normal color. 
Cases of graying in bands have been recorded. In some few 
authenticated cases the hair has turned suddenly and entirely 
white.* 

Other changes in the color of the hair from one shade or color 
to another have been noted, and dyeing, a discoloration from the 
internal or external use of drugs, has also been observed. 

Senile canities is usually observed from the forty-fifth to the 
fiftieth year or later, varying very much in different individuals. 
Persons with very dark or black hair are apt to experience graying 
earlier than blonde-haired persons, although this may occur simply 
from the fact that any change is apt to show more in dark hair. 

Grayness is the result of some lack of pigment production in 
the papilla of the hair, or due to the presence of air in the cortical 
portion. Wilson and Landois have explained sudden blanching 
of the hair by a rapid formation or collection, for some reason, 
of air bubbles, especially between the cells of the cortical layers, 
which renders the hair opaque and white, the contained pigment 
being obscured. 

Canities is usually progressive and permanent, but cases have 
been reported by Jackson t and others where there has been a 
return to the original color. In some cases of graying after acute 
disease in the young the color of the hair has returned on com- 
plete recovery. 

No treatment of canities can be relied upon as effectual. When 
this occurs in the young or in young adults after sickness, tonics, 
as strychnia, quinine, iron, etc., may aid and hasten a restoration 
to the normal when there is a tendency to recovery. The employ- 
ment of dyes and stains to conceal the grayness of the hair is 
rather a matter for the barber to deal with than the dermatologist. 

*Landois, Das Plotzlich Ergrauende Haupthaare. Yirchow's Archiv., vol. xxxv, 
1866, p. 575. Raymond, Revue de Med., 1882, vol. 2, p. 770. Laycock, Brit. 
and For. Med. Chir. Rev., 1861, vol. i, p. 458, and Brown-Sequard, Archives 
de Physiologie, 1869, p. 442, the latter a personal experience. 

t Diseases of the Hair and Scalp, New York, 1890. 



376 DISEASES OF THE SKIN. 

ALOPECIA. 

Alopecia is a general term applied to loss of hair which may 
vary in extent from slight thinning to complete baldness. The 
varieties of alopecia are usually included under the heads of 
congenital, senile, premature and alopecia areata. 

Congenital alopecia is the name given to those rare forms 
of the disease where an individual is born without hair. In 
one such case microscopic examination showed absence of hair 
bulbs. I am acquainted with the case of an otherwise healthy 
infant, upon whose scalp only lanugo (fine downy hairs) grew 
until the third year of life. A hereditary predisposition to scanty 
growth, or early loss of hair, may often be traced. 

Senile alopecia, or the baldness of old age, is connected with 
the general atrophy of the cutaneous tissues which occurs at 
this period of life. The hairs become gray, thin and dry, and 
are cast off, not to be renewed. The hairs of the body generally 
become thinner, and drop out to a less extent, at the same 
time. 

Premature alopecia may be subdivided into idiopathic and 
symptomatic. 

Idiopathic premature alopecia, or premature baldness, may take 
place either rapidly in the course of weeks or months, or, as is 
most generally the case, slowly, through a period of years. The 
hair may begin to come out at any period after puberty, although 
it does not generally fall much before the age of twenty-five to 
thirty. The scalp is healthy to all appearance, no pityriasis being 
present. At first only a few hairs fall, and these are succeeded 
by new ones growing from the same follicles, but coming earlier 
to maturity and falling out before they have attained a normal 
length. The process is progressive, more and more hairs fall- 
ing prematurely. Each new crop of hairs is shorter and finer 
than the preceding, until finally only lanugo or short, fine, soft, 
woolly hairs are produced. In the course of time even these 
are no longer produced; the hair follicles become atrophied, 
and complete baldness ensues. The process is sometimes ar- 



ALOPECIA. 377 

rested and normal hairs may be produced for a time, but the im- 
provement is apt to be transitory. 

This form of alopecia is very common; it is more frequent 
among men than among women; as in senile alopecia, it ordin- 
arily begins about the vertex and extends toward the forehead, 
or it may begin upon the temples. 

Symptomatic premature alopecia includes those forms of more 
or less complete baldness, caused by local or general diseases. 
The loss of hair may be temporary or permanent. Fevers, 
nervous disorders, violent shocks to the nervous system, and men- 
tal distress, worry or overwork, may give rise to sudden or grad- 
ual loss of hair. In a case coming under my own care an attack 
of cystitis seemed to have been the exciting cause. Local affec- 
tions, particularly those attacking the follicles, as seborrhceic 
eczema, lupus erythematosus, etc., may give rise to baldness, 
generalized or in patches, which may be permanent. When 
baldness results from erysipelas, psoriasis, eczema variola, or 
similar affections, the hair is apt to return again after the dis- 
ease has passed away and with the recovery of the general health. 
Syphilis and leprosy also occasion alopecia. In syphilis loss of 
hair occurs in the first general outbreak, just as in other fevers; 
the hair is then usually reproduced. Later in the history of the 
disease it may occur in consequence of local lesions, and when 
these are ulcerative the hair does not grow again. Such cases 
are rare, and the notion that premature baldness is the result of 
syphilis, is absurd, except in the limited sense that debauchery 
may reduce the tone of the general system, and thus give occa- 
sion to falling of the hair. 

The remedies to be used in alopecia must depend upon the 
exciting cause and the circumstances of the disease. The first 
two forms described are, of course, not amenable to treatment. 
Idiopathic premature' baldness, when there is a hereditary ten- 
dency to an early fall of the hair, is almost hopeless as regards 
any permanent effect to be produced by medication. When 
there is no history of early baldness in the family, the disease, 
when taken in hand early, can often be arrested in its progress. 



37^ DISEASES OF THE SKIN. 

Local stimulation is the plan of treatment to be followed. Weekly, 
semi-weekly, or even daily shampooing may be practiced with 
the soap wash known as "spiritus saponis kalinus": 

I£. Saponis viridis, §iv (128.) 

Alcoholis, oij. ( 64.) M. 

Dissolve with heat, and filter. 

This tends to keep the scalp free from the natural accumulation 
of sebum and epidermic scales, and likewise stimulates the cir- 
culation. After shampooing, the scalp is to be thoroughly 
cleansed with clear water, dried as thoroughly as possible, and 
the following "oil" is to be applied: 

1$. Acidi carbolici, gr. xv ( 1.) 

Glycerinae, f oij (8.) 

Aquae cologniensis, ad f§j- (32.) M. 

A good method of applying this oil, so as to get the full benefit 
of it upon the scalp, is to divide the hair in long "parts" by means 
of a comb, and then, with the aid of a dropper, such as is used 
for dropping solutions into the eye, let a drop or so of the oil be 
placed there and here upon the scalp, in the line of the part at 
intervals of an inch, and well rubbed in with a soft brush like 
a tooth brush. Having gone over the scalp in one line thus, 
let new parts be made, parallel with the first, and the same 
procedure gone through with. Thus each portion of the 
scalp is in turn reached by the oil, which is thoroughly rubbed 
into it, a comparatively small portion getting into the hair to 
make a mess, as such applications certainly will do if rubbed in 
at random. 

After a time shampooing with the soap spirit may be dis- 
pensed with, or only employed at long intervals, as, in the case 
of women, especially, this is a very troublesome business. 

The rubbing with the oil should, however, be persevered 
in until the hair has ceased to fall, or until the case must be given 
up as hopeless. The majority of cases, however, will do well 
under this treatment, if carefully carried out. I think that local 
treatment alone can be relied upon in this form of alopecia, but, 



ALOPECIA. 379 

of course, each case must be judged by its total aspect and the 
patient's general health cannot be left out of account. 

Sometimes a hard soap may be used for shampooing. Eic- 
hoff's salicylic acid, resorcin, sulphur and tar soap is a good one 
to use. Rohe, in cases where there is much scaliness, washes 
the scalp with a tar soap and then rubs in the following : 

1$. Pulv. resorcin., oss-j (2.-4.) 

Sp. myrciae, f§xij. ( 360.)- M. 

A small quantity of glycerine, say half an ounce, may be added 
to this formula if the scalp is dry. 

Stelwagon recommends the following: 

1$. Resorcin, 5 j-ij ( 4.-8. ) 

Ol. ricini, n^x-xx ( 0.65-1.33) 

Ol. tiglii, rqiv-xx (0.265-1.33) 

Alcoholis, 

Sen. sp. myrciae., . . . .aa §iv. ( 128. ) M. 

The croton oil is to be used cautiously and in the smallest quantity 
at first, later increasing considerably. 

Lassar recommends that the scalp should be washed with tar 
soap and then a two percent, solution of corrosive sublimate in 
alcohol should be well rubbed in. This should be followed 
by the application of a one to three per cent, alcoholic solution 
of naphtol, to dry the hair, and the scalp should finally be anointed 
with a two per cent, solution of salicylic acid in olive oil. Many 
cases of alopecia do better under treatment by parasiticides than 
under the use of merely stimulating applications. 

If a single application alone is to be used, as in the milder 
cases of alopecia following fevers, etc., the following will be found 
convenient : 

1$. Sodii biborat., 5ss ( 2. ) 

Acid, salicylic, gr. x ( 0.6 ) 

Tinct. cantharidis, f oij ( 8. ) 

Spir. myrciae, 

Aquae rosae, aa 1*5 j ( 32 ) 

Aquae bullientis, ad f§iv. (128. ) M. 

The treatment of that form of alopecia which is in the stricter 
sense symptomatic, such, for instance, as is found in nursing 



380 * DISEASES OF THE SKIN. 

women, in students preparing for examination, and after exhaust- 
ing illness or mental troubles, is in general the same as that above 
given, only that here the patient's general condition is more ob- 
viously at the bottom of the alopecia, and attention must first 
be given to obviating or neutralizing the cause. Iron, quinine, 
arsenic, occasionally cod-liver oil, and, above all, nux vomica 
and strychnia, are the remedies upon which we chiefly depend. In 
addition, moreover, to the local remedies above given, cold- 
water douches, frictions, frequent brushing, and the application 
of one of the stimulating washes to be mentioned under alopecia 
areata, will be found useful. Massage has been employed with 
success in some cases. 

The prognosis in premature idiopathic baldness without obvious 
cause must always be guarded. If we can stop the fall of the 
hair and prevent matters getting any worse, that is about all that 
can be expected. To restore what has been already lost is usu- 
ally more than we can succeed in accomplishing. In baldness 
following fevers, etc., on the other hand, much can be hoped for 
as the result of early and vigorous treatment faithfully carried out. 

ALOPECIA AREATA. 

Alopecia areata is an atrophic disease of the hair system, char- 
acterized by the, usually sudden, appearance of one or more cir- 
cumscribed, whitish bald patches, varying in size and shape, 
or of more or less universal baldness. Alopecia areata may 
attack any portion of the hairy surface, but the scalp is by far 
the commonest seat of the disease. In rare instances the entire 
hair system is involved, and the patient may not only lose the 
hair from the scalp, but that of the eyebrows and lashes, the beard, 
the axillae and pubis, and the fine hairs over the general surface 
of the skin. Upon the scalp the disease is usually observed to 
consist of one or several patches of baldness, roundish, sharply 
circumscribed and conspicuous. They may vary in size from 
a small coin to the palm of the hand. The baldness is generally 
complete, the area presenting a whitish, perfectly smooth, polished 



ALOPECIA AREATA. 



381 



surface, often without a trace of hair. There is sometimes a ring 
of short or broken-off hairs around the margin of the patch. Less 
frequently a thin growth of hair persists over the nearly bald areas. 
The skin is slightly or not at all altered, excepting that the hair 
follicles gradually atrophy. 

The course of the disease is variable; in some instances the 
hair thins out slowly; in other cases a bunch of hair may come 
out in a single night, leaving a fully developed patch. The 




fig. 70. — April 29, 1886. 




July 20, 1886. 



ultimate size of the area is soon reached, and it usually grows 
no larger. When several patches exist they usually form one 
after another, and one may be recovering while another is form- 
ing. The disease may continue weeks, or oftener months, or 
even a year or two; its course is very variable. Relapses are not 
uncommon. A growth of lanugo, or fine, downy hairs, often 
occurs in the course of the disease, leading to the false hope that 
the hair is at length about to return; but the soft, fine hairs drop 
cut again, leaving the patch as bald as before. When, however. 



3 82 



DISEASES OF THE SKIN. 




*Fig. 72. — October 12, iS86. 



Fig. 73. — December 16, 1886. 




Fig. 74.— February 18, 1887. Fig. 75.— April 18, 1887. 

* These series of plates (Figs. 70 to 75) show the course of a typical case of 
alopecia areata from beginning nearly to end. 



ALOPECIA AREATA. 383 

complete repair once sets in, recovery is occasionally rapid. The 
new hair is sometimes at first pale, gray, or mixed in color, sub- 
sequently assuming the normal or even a darker shade. There 
are no subjective symptoms, as a general thing, but patients now 
and then suffer from neuralgia, or notice a premonitory itching, 
heat, or soreness. 

The causes which produce the disease are not understood. 
Some cases may possibly be parasitic in character, and all cases 
occurring in children must be now considered as suspicious with 
regard to the possibility of contagion. (See Ringworm of the Scalp.) 
We should warn patients, particularly children, against exchang- 
ing caps and otherwise coming into close 
contact with those suffering from this 
affection. 

This matter should be considered 
also in giving certificates to school 
children who may have suffered from 
alopecia areata.* The majority of 
cases of alopecia are, in all likelihood, 
due to some functional nerve distur- 
bance. It has been noted to follow FlG - 7&— Alopecia areata fol- 

lowing wound of nerve. 

neuralgias, sudden nervous shocks, and 

debility resulting from various causes. In many cases, however, 
patients enjoy excellent health, and no appreciable cause for the 
attack can be assigned. Occasionally alopecia areata appears to 
be hereditary. Crocker t reports cases of the disease extending 
through three generations. The affection is not a very uncom- 
mon disease, the American statistics showing its occurrence in 
794 of the 123,746 cases reported, i.e., in .641 per cent. 

Alopecia areata is more apt to be mistaken for ring- worm of 
the scalp than for anything else. The suddenness of the attack, 
however, the more or less complete baldness, the absence of 
desquamation, the whiteness and remarkable smoothness of 

* See a very interesting account of an epidemic of alopecia areata, occurring 
in Boston, by Dr. John T. Bo wen, British Journal of Dermatology, March, 1894, 
p. 80. 

t British Journal of Dermatology, vol. v, June, 1893, p. 176. 




384 DISEASES OF THE SKIN. 

the patch, always enable it to be distinguished from tinea ton- 
surans. Difficulty can only arise in old cases of ring- worm, 
where the short, characteristic hairs have disappeared; but even 
here more or less desquamation exists, with a grayish, "goose- 
flesh" like surface, very different from the ivory-like appearance 
of the scalp in alopecia areata. Tinea tonsurans begins as a 
small patch and spreads slowly ; there are always, or almost inva- 
riably, a certain number of nibbled-looking, broken-off hairs in 
the patch, and there is a history of contagion. The microscope 
revealing the characteristic fungus (see under ring-worm) will 
settle the matter, and should always be employed in cases of 
doubt. 

But as has been remarked above, the two affections may 
occur simultaneously, or nearly so, in the same individual, a point 
to be taken into consideration. 

The treatment of alopecia areata should be both internal and 
external. The ordinary tonics — iron, quinine, arsenic and nux 
vomica, or strychnia — are ordinarily to be employed. In some 
cases, phosphorus and cod-liver oil may be given with advantage. 
Often the patient's general health appears to be perfect, and 
only after long and careful search can the weak point be found 
to which the failure in nutritive power is to be attributed. Occa- 
sionally the minutest examination will fail to yield any evidence 
of disturbance of the normal equilibrium of the system. Treat- 
ment must then be purely empirical. Hygiene is always of 
importance. 

The external applications which have been found useful, or 
which have been thought to be of use, in alopecia areata, have 
mostly been directed with a view to one object, namely, to 
stimulate the skin and to cause a more active flow of blood to the 
affected parts. Alcohol, cantharides, the essential oils, carbolic 
acid, iodine, turpentine, ammonia, tannic acid, nux vomica, 
pepper, quinine, sulphur, kerosene oil, and crude petroleum, have 
been employed at one time or another. These substances 
may be applied either in the form of ointments or of lotions, 
in sufficient strength to produce a stimulant or rubefacient 



ALOPECIA AREATA. 385 

effect, once or twice daily, as occasion may require. Before 
making any of these applications it will be well to have the scalp 
or other affected part washed well with castile soap and water, or, 
better, with the " spiritus saponis kalinus." (See Alopecia.) After 
washing, the scalp is to be dried with a coarse towel, and brushed 
with a thick-set but not too stiff brush, until moderately stimu- 
lated. 

One of the hard medicated soaps may also be employed. In 
view of the possible presence of a parasite a bichloride soap per- 
haps would be preferable. 

Patients sometimes express the fear that a vigorous applica- 
tion of the external remedy may itself produce baldness to a 
greater degree, but it will be found that after the patches have 
fairly formed the remaining hairs are firmly seated. Among 
the formulae published in such numbers in books and medical 
journals, those following will be found most efficient. 

R. Tinct. cantharidis, 

Tinct. capsici, aa fgss (16.) 

Olei ricini, 5ss ( 2.) 

Aquae cologniensis, f § j. (32.) M. 

Sir Erasmus Wilson used to recommend the following: 

1$. Olei amygdalae dulcis, 

Liquoris ammoniae fort.,. . . .aa foss ( 16.) 

Olei limonis, f 5ss ( 2.) 

Spiritus rosmarini, ad f§iv. (128.) M. 



Wilson also recommended frictions with a liniment of aconite 



etc. 



1$. Tinct. aconiti rad., f oiv (16.) 

Chlorof ormi , foij ( 8.) 

Liquor ammoniae, f 5 j (4-) 

Pulv. camphorae, oj (4-) 

Olei olivae, ad foij (64.) M. 

Oil of turpentine, brushed or rubbed into the patches with a 
small stiff brush, once a day or less frequently, until the scalp 
becomes sensitive, is recommended by some writers. The late 
Tilbury Fox recommended the following, which I have used 
with satisfaction: 
25 



386 DISEASES OF THE SKIN. 

1$. Tinct. nucis vomicae, f§ss (16.) 

Tinct. cantharidis, f 3vj (24.) 

Glycerinae, f5ij ( 8.) 

Aquae destillatae, f §iss (48.) 

Aquae rosae, fSiij- (96.) M. 

I have sometimes blistered the bald patches with cantharidal 
collodion with success. Crocker, while blistering recent patches, 
directs the loose hairs about the patches to be pulled out and 
the following ointment rubbed in: 

1$. Chrysarobin, 3ss-j ( 2.-4.) 

Lanolin, oj (32. ) 

Olei olivae, q. s. M. 

Some caution should be employed in the use of this remedy 
on account of its tendency to produce inflammation. 

Another prescription recommended by Crocker as well as 
others, is the following: 

1$. Hydrarg. bichlor., gr. ij-v ( 0.10-0.30) 

Alcoholis, f 3j ( 4-) 

Olei terebinthinae, f ovij. (28. > M. 

Bulkley recommends a 95 per cent, solution of carbolic acid 
brushed lightly over the affected surface with a swab and then 
rubbed in. I prefer trikresol for this purpose. 

All of these forms of treatment prove useful at one time or 
another, but unfortunately, any or all may at times prove unsuc- 
cessful. One after another should be tried with great persever- 
ance. 

Electricity also is used in some cases with advantage, four to 
ten cells of the constant current battery being used, and the 
negative pole placed in contact with the diseased patch. The 
treatment of alopecia of the beard is essentially the same as that 
of alopecia of the scalp. 

The prognosis of alopecia areata should be guarded. Sometimes 
recovery takes place in a few months, in other cases it may be 
delayed for years. Now and then the hair is not restored at all. 
As a rule, in young persons, the baldness is not permanent. 
Treatment should be persevered in. 



ALOPECIA AREATA. 38 



Alopecia Syphilitica. Loss of hair occurring in the course of syphilis 
may result from early or late lesions of the scalp. The early form of syph- 
ilitic alopecia usually occurs in the first months of the disease and is unac- 
companied by any lesions perceptible to the naked eye. Its most character- 
istic feature is its generally disseminate character. The hair is thinned on 
various irregular areas over all parts of the scalp, and the loss is not usually 
confined to any one locality. In rare cases, however, alopecia areata may 
occur in similar disseminate patches of thinning, so that this characteristic 
of syphilitic alopecia is not absolutely diagnostic. 

The hairs in syphilitic alopecia are dry and dead looking, and seem to be 
attenuated. The hair bulbs are atrophied. They fall rapidly, sometimes 
"by the handful," as patients express it. However, every degree of bald- 
ness may be observed at one time or another in different cases. In rare 
cases generalized alopecia over the whole body is observed. A very conspic- 
uous symptom of syphilitic alopecia is the denudation of the external part of 
the eyebrow on one or both sides. This is not, as is sometimes asserted, 
pathognomonic. It may occur in alopecia areata, and also in keratosis pil- 
aris. 

The best treatment of this form of alopecia is that demanded by the syph- 
ilitic disease, and the earlier this is undertaken, when once the diagnosis of 
syphilis has been arrived at, the less likely is alopecia to occur, and the 
more trifling in any case is the fall of hair likely to be. 

Lotions of bichloride of mercury, 1 to 1000 or 1 to 500, are called for in 
the early stages of the alopecia, and these may be followed by the following 
pomade when the case will admit: 
1$. Quiniae sulphat., 

Turbith. mineral., aa gr. viij ( 0.50) 

Medullae bovis, o j- (32. ) M. 

These applications may be alternated every few days with the following: 

1^. Sodii carbonat., 

Sodii biborat, aa gr. xx ( 1.20) 

Aquae destillat., f 5v (160. ) M. 

Fournier has the hair cut short; washed well with sapo viridis and hot 
water every morning, and the rcalp well subbed with the following pomade: 

1^. Acid, salicylic gr. xv ( 1.) 

Sulphuris prsecipitat., o ss (2.) 

Lanolin, 

Vaseline, aa o iv. (16.) M. 

In the evening the scalp is brushed with the following: 

ly. Acid, salicylic, gr. xv ( 1.) 

Tinct. cantharidis, f 5 ss ( 2.) 

Tinct. rosmarin., ad f5 iv. (128.) M. 



388 DISEASES OF THE SKIN. 

The prognosis of alopecia syphilitica is almost always favorable. In some 
cases, when the patient has a hereditary tendency to premature baldness, 
where the health is much impaired, or at a more or less advanced age, a 
complete restitution does not take place; but in general a tolerably speedy 
return to the normal condition may be predicted. 

FOLLICULITIS DECALVANS. 

Folliculitis decalvans is a rare inflammatory disease of the 
hair follicles, resulting in destruction of the follicle with scarring. 
The disease is usually found upon the scalp, especially on the 
anterior portion, but it. may occur on the beard or in the pubic 
and axillary regions. The first lesion is a pin-head papule 
or red follicular elevation or it may be a small pustule. The 
center is pierced by a hair as in sycosis. This soon loosens and 
falls out and a cicatrix results. The lesions may be discrete 
and scattered or they may occur in a patch. As usually seen, 
there is a central coin-sized, -roundish, depressed, bald, cicatricial 
patch, smooth, white and glistening, the periphery studded here 
and there with the minute, red, follicular elevations, Pustules or 
crusted points. Occasionally one or two islets of hair may be seen 
in the cicatricial area. The disease, though slow, is progressive 
and destroys the hair follicles and often all the dermic tissues. 
In another form of the disease the patches resemble those of 
alopecia areta excepting that they are cicatricial and there is a 
faint rose-tinted border when the hairs can be extracted easily; 
sometimes there is a ring of keratosis. The treatment is that of 
sycosis. 

SYCOSIS VULGARIS. 

Sycosis is an acute or chronic, inflammatory, parasitic affec- 
tion, involving the hair follicles, and often the perifollicular 
structures, characterized by pustules, papules, and tubercles, 
perforated by hairs, accompanied by burning and itching. 
The disease is confined to the beard and hairy parts of the face. 
Papules and then pustules form, each one having a hair as its 
center, and showing little inclination to rupture. The pustules 



SYCOSIS VULGARIS. 389 

are generally discrete, but are sometimes so numerous as to be 
crowded together. They are accompanied by marked redness 
of the surrounding skin, sometimes by swelling, burning, and 
pai . and result in a cicatrix. Unless the suppuration is pro- 
fuse, the hairs cannot be extracted without giving much pain. 




Fig. 77. — Sycosis Vulgaris. (Courtesy of Dr. Duhring.) 



It sometimes occurs on the upper lip, following catarrh of the 
nose. It occurs equally in those who shave and those who do 
not. 

The essential cause of sycosis is microbic. The pyogenic 



39° DISEASES OF THE SKIN. 

cocci (staphylococcus aureus and albus) are the usual causative 
agents. The disease is feebly contagious. 

The micro-organisms gaining access give rise to the inflam- 
matory changes and the clinical manifestations, and the process 
starting at one point soon involves neighboring follicles by 
continuous and repeated inoculation. The disease is primarily 
a perifolliculitis, the follicles and their sheath becoming rapidly 
involved secondarily in the inflammatory process. The hair- 
papilla is not as a rule destroyed, so that hair loss except in 
very chronic and markedly suppurative cases does not com- 
monly occur. 

Sycosis is apt to be mistaken for eczema of the beard, and 
sometimes for tinea sycosis, or true barber's itch. From the 
latter it is, however, distinguished by several marked features. 
In both affections the hair follicles are attacked, but in the para- 
sitic disease the lesions are simply large, rounded, red lumps, 
or variously-sized nodules, with few or no pustules. The hairs, 
however, in spite of the fact that there is no suppuration about 
their roots, come away easily, and sometimes drop out spon- 
taneously. The presence of the spores of the vegetable parasite, 
when looked for in the roots of the diseased hairs under the 
microscope, will greatly aid in the diagnosis. (See Tinea sycosis.) 
From eczema of the beard sycosis is distinguished by the absence 
of oozing or weeping, and also by the fact that eczema rarely 
attacks the beard without showing itself elsewhere. It spreads 
about in pustules and crusts in the neighborhood, while sycosis 
is strictly marked by discrete pustules, each with its hair running 
through the center. 

External treatment is that most generally useful in sycosis. 
Exposure to irritating influences is to be avoided. The hair 
should be kept clipped close or shaved. The latter is to be 
preferred. Although painful at first, I regard it as the sine 
qua non of successful treatment, and usually insist upon it. In 
this, as in some other matters, it is only the first step which costs; 
after shaving a few times, the patient is brought to see the 
reasonableness of the procedure by the comfort which it brings 



SYCOSIS VULGARIS. 39 1 

Shaving should be practiced every second or third day, according 
to the rapidity with which the beard grows. When shaving is 
to be performed for the first time, the hairs should first be clipped 
close, and then a poultice should be applied, to soften the crusts. 
When there is much inflammation, this poultice may be made 
of bread-crumb and dilute lead-water, and applied cold. This 
is very soothing. After such careful preparation, shaving is a 
much less painful operation than it would otherwise have been. 
Shaving having been established as a habit, the local medical 
treatment may be put into operation. When the disease is 
acute and there is a good deal of pain and swelling, black wash 
may be thoroughly applied every two or three hours, followed 
each time, as soon as it is dry, by oxide of zinc ointment, gently 
applied by means of the finger, or spread upon pieces of soft 
linen and bound upon the parts. 

The following wash, not to be followed by ointment, is like- 
wise of service in acute sycosis: 

1$. Pulv. zinci carb. praecip., 

Pulv. zinci oxidi, aa . . . . oij ( 8. ) 

Glycerinae, 

Liq. plumbi subacetat. dil., .. .aa. . . . f oij ( 8. ) 

Aquae rosae, f oviiss. (230. ) M. 

In subacute cases the following wash is very good: 

1$. Sulphur, praecipitat., 3ij ( 8. ) 

Pulv. camphorae, gr. x ( 0.6) 

Pulv. tragacanth, 9j ( 1.2) 

Aquae calcis, foiv. (128. ) M. 

SiG. — Shake well, and apply two to four times daily. 

This sometimes succeeds when all else fails. 
If ointments are employed, the following will be found sooth- 
ing, in the acute stage: 

1$. Pulv. zinci carb. praecipitat., 

Pulv. zinci oxidi aa 5j ( 4.) 

Ung. aquae rosae, §j, (32.) M. 

To be applied immediately after shaving. 

In other cases depilation of pustules, washing with and the ap- 
plication of five per cent, alcoholic solution resorcin to each affected 



39 2 DISEASES OF THE SKIN. 

follicle is practiced. Sulphur, resorcin, ichthyol, pyrogallol, 
and chrysarobin ointments, two to five per cent, are used, or 
ichthyol in ten per cent, strength in water, as a fomentation. 
Mercurial ointment, with ten per cent, carbolic acid, and up 
to one per cent, corrosive sublimate, is also useful. If the beard 
cannot be shaved, each affected hair must be extracted, the 
follicle washed out, a^d a zinc-sulphur or weak resorcin sublim- 
ate salve then applied. Rhinitis, which is often present in sycosis 
of the upper lip, should be treated by the nasal douche with a 
one per cent, solution of ichthyol in water, or by other means 
commonly employed. 

When the affection is of long standing, and when there is 
much infiltration, sapo viridis well rubbed in with a flannel rag 
and a little water, and after washing off followed by ung. diachylon, 
may be employed. When the eruption exists only at one or two 
points, and is subacute or chronic, stronger stimulants may be 
used. Sulphur ointment, half a drachm to a drachm to the ounce, 
or one of the mercurial ointments, may be employed. Depilation 
is only to be used when the roots of the hairs are loosened by sup- 
puration. 

For some time after the disease appears to be cured, the face 
should be shaved (using sublimate soap), and each inflamed 
follicle that may appear should be treated as above, and followed 
by one of the ointments. 

The prognosis in sycosis should be guarded, for, while some 
cases yield readily to treatment, others, particularly when the 
disease involves a considerable area of the face, last for months, 
and even years, in spite of the most assiduous attention. Re- 
lapses are not uncommon. 

3. DISEASES OF THE SEBACEOUS GLANDS. 

SEBORRHCEA. 

Seborrhea is a disease of the sebaceous glands of the skin, 
characterized by an increase in the quantity of the sebum poured 
out, and also, in most cases, by an alteration in quality of the 
secretion. There are two varieties, S. oleosa and S. sicca. 



SEBORRHCEA. 393 

Seborrhea oleosa appears in the form of an oily coating upon 
the skin, giving it an unctuous and greasy feel. Its most com- 
mon seat is on the scalp and about the face, particularly the nose 
and forehead, where it appears as a greasy coating, containing 
more or less dust and dirt, and looking as though the skin had 
been smeared with dirty ointment.* In the scalp it collects on 
the hair, giving it a dark, limp look, as if it had been freely oiled, 
or when the scalp is bald it looks as if oil had been poured over it. 

Seborrhea sicca, or dry seborrhcea, occurs in infants as the 
vemix caseosa or smegma of the new-born. Here it is almost 
physiological, and is usually soon removed. If it remain, it 
becomes a diseased condition, and as such is often seen on the 
scalp. Dry seborrhcea shows itself on both the hairy and non- 
hair} 7 portions of the body, as a more or less greasy mass of 
scales, of a dirty, yellowish color, and somewhat adherent to the 
skin. On the scalp, these masses are larger and oilier, tending 
to cling to the skin in thick plates, and leaving, when picked 
off, a smooth, grayish, moist or oily surface beneath. In old 
persons the scalp, and sometimes the region of the beard, is 
covered to a greater or less extent, with a brown, adherent, 
greasy coating, which is essentially seborrhceic in character. 

Seborrhcea sicca of the scalp, like eczema seborrhceicum, with 
which it is sometimes confounded (see Eczema seborrhceicum), 
is sometimes followed in the young by premature baldness. 
If taken in time, however, baldness from this cause can be 
prevented, or at least postponed, and it is desirable in all cases 
to remove the seborrhceic condition, even if it gives rise to little 
or no annoyance. 

Seborrhcea of the foreskin and glans penis is an abnormal 
flow of the normal secretion of this part, known as smegma 
preputii. If unattended to, it leads to balanitis, from the irrit- 
ation of its rapidly decomposing sebaceous products. 

* In rare cases this secretion as it occurs over the nose and adjacent parts of 
the cheeks takes on a bluish-black color, the so-called " Seborrhcea nigricans." 
What part is played by the sweat glands in this condition has never been made 
perfectly clear and some writers have included such cases under the head of 
" black chromidrosis." 



394 DISEASES OF THE SKIN. 

Seborrhoea is induced by a variety of causes, prominent among 
which is the chlorotic or anaemic state. It is more apt to occur 
about puberty, or in early adult age. It may occur in persons 
otherwise healthy. In such cases it is usually curable by local 
measures. 

The diagnosis of seborrhoea is usually not a matter of much 
difficulty; the evidently sebaceous character of the lesions point- 
ing out its nature with sufficient certainty. Seborrhceic eczema, 
however, closely resembles seborrhoea and the line of demarca- 
tion between them is in some instances uncertain. 

The treatment of seborrhoea should usually be both constitu- 
tional and local. Fresh air and exercise, especially in the case 
of young women, is to be insisted upon. Attention should also 
be paid to diet. The history should be looked into, and any 
functional irregularities corrected when possible. Success in 
treatment often depends upon ascertaining and meeting the 
exciting cause in the individual. Cod-liver oil, iron, and arsenic 
are the most generally useful remedies. The following is a 
useful prescription: 

1$. Tinct. ferri chlor., 

Acid, phosphoric, dil., foj (32.) 

Syrupi limonis, f o i j • (64.) M. 

SiG. — Half a teaspoonful to a teaspoonful, in a wineglass of water, three 
times a day. 

Arsenic is best given in the form of Fowler's solution, in four- 
minim (.24) doses at first, gradually increased until the disease 
begins to disappear, or until the limit of tolerance is reached. 
It should never be prescribed to be taken in drops, but always 
in combination with some adjuvant. The following is an 
excellent formula : 

1^. Liq. potas. arsenit., 3ij ( 8.) 

Vini ferri, ad f§iv. (128.) M. 

SiG. — A teaspoonful after meals, in water. 

The local treatment of seborrhoea is very important. In 
seborrhoea of the scalp the scales and crusts must first be removed. 
If hard and caked, as is sometimes the case in old people, the 



SEBORRHCEA. 395 

scalp should be soaked in oil over night. Hot water and castile 
soap will then remove the softened crusts, or, if this should fail, 
the alcoholic solution of sapo viridis, known as "spiritus saponis 
kalinus," may be employed. A teaspoonful of this may be ap- 
plied to the sca'p with a sponge and a considerable quantity of 
warm water added, so as to make a lather. After vigorously 
shampooing the scalp for a few minutes, the soapy matters are 
to be washed away with an abundance of clear, warm water, the 
scalp dried quickly with a soft towel, and it is ready for the 
application of the more strictly remedial agents. These should 
be in the form of oils, if the hair is at all thick, because oint- 
ments are so apt to stick the hairs together and make a mess. 
The sort of application to be made will depend upon the con- 
dition of the skin. Generally the scalp will bear more stimulat- 
ing applications. Of these, carbolic acid is one of the most 
efficient, as in the following combination: 

R. Acidi carbolici, gr. xv ( i.) 

Ol. ricini, aa qss ( 2.) 

Ol. limonis, 

Aquae cologniensis, ad f5j. (32.) M. 

Sig. — Apply after washing. 

When there is little hair upon the scalp, the following ointment 
may be used: 

1$. Sulphuris praecipitat., 3j (4-) 

Ung. petrolii, : 5 j. (3 2 -) M. 

Sig. — A small quantity to be rubbed in, once a day. 

This preparation is also useful in seborrhcea about the body. 
Another preparation useful about both scalp and body, 
especially in S. oleosa, is this: 

ly:. Acid, tannic, 3 j (4-) 

Ung. petrolii, §j. (32.) M. 

Mercurials are sometimes of value. Either ointment of the 
red oxide of mercury, 2 to 5 per cent., or the ointment of nitrate 
of mercury diluted with 4 to 6 parts of vaseline may be employed. 
In severe and stubborn cases Vidal uses multiple scarifications 



39^ DISEASES OF THE SKIN. 

with the view of cicatrizing the enlarged oil glands, and I am 
inclined to believe that the X-ray will be useful in a certain number 
of cases. 

The prognosis of seborrhcea will depend upon the duration 
and extent of the disease and upon the patient's general health. 
Dry seborrhcea can generally be gotten well, under proper treat- 
ment, in a reasonably short time. But when in the scalp and 
mixed with more or less seborrhceic eczema, the prognosis is 
not so favorable. Premature baldness may follow neglected 
seborrhcea. If the hair has already begun to fall out a cautious 
prognosis must be given. Even if the most active treatment 
is followed out there is little hope of bringing back the hair, 
although its fall may be arrested. 

ASTEATOSIS. 

Asteatosis is the opposite of seborrhcea and is characterized by a diminu- 
tion in the amount of sebum secreted by the skin. It occurs in senile dry- 
ness of the skin, in connection with ichthyosis, prurigo, pityriasis rubra pil- 
aris, scleroderma, dermatitis exfoliativa, long-continued scaly ~czema, etc. 
The secretion of the sweat glands is apt to be diminished at the same time. 

The condition, for it is such rather than a disease, may be mitigated by 
the substitution of inunction with fats to take the place of the natural se- 
cretion. When partial asteatosis results from failure in general nutrition 
the condition disappears with the return of health, or when it occurs in con- 
nection with curable skin diseases it disappears as those get well. In other 
cases the condition is apt to persist. 

MILIUM. 

Milia are small, rounded, whitish or yellowish, pearly, non- 
inflammatory elevations, situated in the skin just beneath the 
epidermis. They are usually met with upon the face, although 
they may occur elsewhere, particularly on the penis and scrotum 
and upon the labia majora. They may occur singly or in great 
numbers, and when formed may last for years without change. 
They give rise to no subjective sensations, and no annoyance, 
beyond the slight disfigurement which they cause. In rare in- 
stances one or more of the larger ones may undergo calcareous 



STEATOMA. 397 

metamorphosis. Milia are met with at all ages but are particu- 
larly common in adolescence and early adult life, especially in 
women. 

The affection consists in an accumulation of sebum within the 
sebaceous gland, which owing to the obliteration of the duct- is 
unable to escape. In other words milia are retention cysts. 
They do not tend to grow beyond a certain very small size and 
do not degenerate or become malignant. The treatment con- 
sists in opening each one of the little pearly cysts, squeezing 
out the cheesy sebaceous matter which forms its contents and 
cauterizing the sac with a point of nitrate of silver or a drop 
of iodine. 

STEATOMA. 

Steatoma, also known as sebaceous cyst or wen, appears as 
a variously-sized, firm or soft, roundish tumor, seated in the 
skin or subcutaneous connective tissue. The skin covering the 
tumor is natural in color, or whitish, from stretching. The 
tumors may occur singly or in great numbers, and vary in size 
from that of a pea to a walnut or larger. They are usually firm, 
but sometimes doughy, and are generally freely movable and 
painless. Their usual seat is upon the scalp, face, back, and 
scrotum, though they may be met with anywhere, even on the 
soles of the feet. They may last for years unchanged, but some- 
times break down and ulcerate. They may degenerate into 
epithelioma in old persons. Some sebaceous cysts are flat, with 
a minute hole in the center; others tend to rise and become 
semi-globular. The latter are those commonly found on the 
scalp, where they are devoid of hair. 

The contents of a sebaceous cyst may be milky or cheesy in 
consistence, and are often decomposed and fetid. The tumors 
are enormously distended, sebaceous ducts and glands, the walls 
of which have become hypertrophied until they form a tough sac. 
Sometimes calcareous masses are found in sebaceous cysts and 
occasionally the cyst opens and a papilloma or even a cutaneous 



398 DISEASES OF THE SKIN. 

horn develops and appears through the opening. Hairs are 
also found at times. They are benign tumors and rarely de- 
velop malignant growths. 

The treatment of sebaceous cyst is by incision of the mass 
and dissecting out the complete enveloping sac. In small tumors 
incision and the introduction of a bit of nitrate of silver will 
cause eversion of the sac, or the electric needle may be used. 

COMEDO. 

Comedo is a disorder of the sebaceous glands, characterized 
by yellowish or whitish, pin-head size elevations, containing in 
their centre blackish points. Very often the black points appear 
alone upon the unchanged skin. The disease is observed chiefly 
about the face, neck, chest, and back. Each single elevation is 
called a comedo (plural comedones). The common name 
" flesh worms," or "grubs," is calculated to convey the erroneous 
idea that the small inspissated plug of altered sebum which can 
be expressed from the follicle is a parasitic worm. It is true that 
a little mite, the microscopic Demodex folliculorutn, is occasionally 
found in the mass, but this cannot be regarded as in any way 
essentially connected with the disease. Its presence is merely 
fortuitous and without significance, the plug consisting of altered 
sebaceous matter, mingled with epithelial cells. The affection, 
though comparatively trifling, and' without subjective symptoms, 
is often extremely annoying to patients. It is due in part to 
idiosyncrasy, in part to a general sluggish performance, not only 
of the functions of the skin, but also of those of the whole body. 
Patients are apt to suffer from dyspepsia and with constipation. 
In young women chlorosis and menstrual difficulties are apt to 
be present. The disease is pre-eminently one of the period of 
puberty; patients seeking relief from this complaint are almost 
invariably young men and young women, although the disease 
may occur in infants and young children. 

Crocker and other English dermatologists have reported a 
form of comedo occurring in children, which appears to be con- 



comedo. 399 

tagious. It occurs ordinarily on either side of the forehead in 
groups, rather than disseminated irregularly as the lesions of 
ordinary comedo are.* 

Local treatment suffices in some cases to relieve the condition. 
Frequent bathing of the affected surface with hot water will 
aid the process of removal. Stimulating ointments, especially 
such as contain sulphur, are useful, as the following: 

Of. Sulphur, praecipitat., 5j (4.) 

Ung. aquae rosae, §j. (32.) M. 

Sig. — To be rubbed in at night. 



Sulphur lotions, such as those given under the head of acne, 
may also be useful. Should the skin tend to become harsh under 
the use of these remedies, weak alkaline ointments may be used 
for a time, as this: 

1^. Sodii biborat., oss (2.) 

Glycerinae, rr|xvj ( 1.) 

Ung. aq. rosae, oj. (32.) M. 

An excellent application is the following: 

1$. Aceti, oij ( 8.) 

Glycerinae, oiij ( 12.) 

Kaolini, oiv. (12S.) M. 

This forms a soft paste, which is to be spread over the surface at 
night, and, if possible, in the morning also. If applied on the 
face, the eyes should be kept shut, on account of the pungency 
of the vinegar. It loosens and dislodges the sebaceous plugs 
more satisfactorily than any other preparation with which I am 
acquainted. A watch-key or one of the "comedo expressors" 
sold by surgical instrument makers, may be employed to press 
out the comedones, the end being gently but firmly pressed down 
over the sebaceous plug. Should this not yield readily, the point 
of a fine needle may be run into the follicle, alongside of the 
comedo, and then moved around, so as to loosen and detach the 
plug from its surrounding wall. Care should be taken not to 
use too much force, for fear of inflaming the skin. The staphy- 

* Crocker, Lancet, 1S94, i, p. 704, and Colcott Fox, lb., 1888, i, p. 665. 



400 DISEASES OF THE SKIN. 

lococcus pyogenes is usually present, and if pressed down into 
the succulent tissues in the neighborhood finds its favorite pabu- 
lum and gives rise to a pustule. If the comedo plug does not come 
out easily, it should be left for another time. It must be remem- 
bered that so long as the condition which produces comedo is 
present and effective, the comedones are apt to be reproduced. 
Several in succession may have to be removed from the same 
glandular opening. In carefully selected cases the X-ray em- 
ployed with caution will cure very obstinate cases. The patient 
should be warned, however, that numerous minute cicatricial 
pits may be left after the treatment is completed. 

Occasionally the tonic internal treatment required in acne 
(see Acne) is called for. 

Sometimes the contents of the sebaceous follicles become 
even more condensed and hardened than above described. The 
firm, almost horn-like plugs are gradually forced out of the mouth 
of the follicles, until they may stand up stiffly above the surface 
of the skin. Such a case came under my notice some years ago, 
the skin of the body, particularly over the shoulder, being the 
seat of the disease. The hardened sebaceous plugs, in great 
numbers, projected to the height of an eighth of an inch or 
more, giving the surface of the skin a nutmeg-grater appear- 
ance, viewed from a little distance. Hot baths, frictions with 
sapo viridis, and inunction of sulphur ointment may be used 
in such cases. Occasionally a horny outgrowth occurs in comedo. 
Sometimes this is a kerotasis (see Keratosis). At other times, 
as in a case I once had under observation, a bunch of fifteen to 
twenty hairs are found growing out of each lesion. 

ACNE. 

Sometimes called acne vulgaris, is an inflammatory disease of 
the sebaceous glands, characterized by the formation of papules 
or pustules, or a combination of these lesions, together with a 
certain degree of erythema, and occurring chiefly upon the face 
and over the shoulders, although it may occur upon any part of 
the surface where sebaceous glands exist. 



ACNE. 



401 



It may occur alone or in connection with other affections of 
the sebaceous glands, as comedo and seborrhcea. The lesions 
are of various size, from a pin's head to a large split pea, and 




Fig. 78. — Acne with Comedo. (Courtesyof Dr. Duhring.) 

are commonly seen in both the papular and pustular, or the tuber- 
cular and pustular forms combined. 
26 



4-02 DISEASES OF THE SKIN. 

The pustules of acne are pin-head to large pea-sized, rounded 
or acuminated, seated on a more or less infiltrated base of super- 
ficial or deep inflammatory product. Suppuration may be 
slight or abundant. When the base is deeply infiltrated the 
affection is known as acne indurata. In this last form the process 
sometimes runs on to the production of abscesses, which appear 
chiefly on the face and down the shoulders and back, forming a 
most serious and annoying phase of the disease. Indurated acne 
is apt to result in the formation of cicatrices of a pitted or atro- 
phic character, which are quite disfiguring. Sometimes keloid 
occurs as a result of indurated acne, the lumpy scars lasting some 
months, but finally, in most cases, disappearing spontaneously. 

There is usually no discomfort from the lesions excepting a 
feeling of soreness when touched. Their color is bright red to 
dusky violaceous. 

The number of lesions varies in different cases from one or two 
to a very great number. The inflammation may be superficial 
or deep, even forming abscesses. The individual lesions may 
run their course in a few days, but the course of the disease, as 
a whole, is apt to be chronic, running on for years. If there has 
been much suppuration, more or less unsightly scars may remain. 

Acne is one of the commonest diseases of the skin. It occurs 
in the young of both sexes, appearing about the age of puberty. 
It does not often occur in children, and, on the other hand, only 
rarely makes its appearance for the first time in mature years. 

The causes predisposing to acne are numerous and varied in 
their nature. In its commoner forms it appears to be depen- 
dent to some extent upon the character of the skin. Persons 
with thick, oily skins are most apt to suffer from the diffuse form 
of acne, with numerous papular and pustular lesions mingled 
with comedones, while the sparse eruption of flat and papular 
lesions is often found in pale, anaemic individuals with dry, rather 
harsh skins. The most frequent predisposing cause of acne is 
puberty. The affection shows itself for the first time, in the vast 
majority of cases, at this period, and is apt to continue, unless 
remedial measures are adopted, until the system has assumed 



ACNE. 403 

the equilibrium of adult life, or in women until a later period. 
It is at the period of puberty that the sebaceous system takes on 
a new activity, the hairs begin to develop, and there is a sort of 
normal hyperemia about the follicles, which may easily deter- 
mine an abnormal condition resulting in the development of 
sebaceous disorders. 

Other causes which may, either alone or combined, predispose 
to the occurrence of acne are "scrofula" and cachexia ("acne 
cachecticorum") or general debility. Anaemia and chlorosis 
may also be mentioned in close connection with these other causes, 
as favoring the development of acne, and in the more markedly 
pustular and indurated varieties a family history of tuberculosis 
is very often noted. 

Of great importance in the causation of acne, and especially 
in favoring its continuance, is habitual derangement of the ali- 
mentary canal. Dyspepsia and constipation will be found pres- 
ent in the majority of cases, and often in such intimate relation 
to the disease that a fresh crop of lesions shall follow every attack 
of indigestion or of costiveness. 

Disease of the nasal cavities may at times occur in connection 
with acne, but its causative influence has not been satisfactorily 
established. 

Uterine disorders, especially of a functional character, are often 
the indirect cause of acne; but at other times the remote cause of 
the affection seems beyond finding out, the patient remaining in 
an apparently perfect condition of general health. 

The question as to the immediate cause of acne is a disputed 
one. Some observers maintain that there is a parasitic factor. 
The pus organisms have been believed to be the chief immediate 
cause of the disease but Gilchrist * and others have demonstrated a 
special bacillus, and believe that the cocci found are somewhat 
distinct from the ordinary pus cocci. 

It would appear that the existence of seborrhcea predisposes 
to some forms, at least, of acne. Seborrhceic eczema of the scalp 

* Trans. Am. Dermatolog. Assn., for 1899, p. 97, and Jour. Cutan. Dis., 1903, 
p. 107. 



404 DISEASES OF THE SKIN. 

is a very common, in fact almost constant, accompaniment. 
The existence of comedones favors the occurrence of acne but the 
blocking up of the duct is not the cause of the disease. That the 
etiologic factor is present in the comedo, would, however, appear 
from the fact that pressure to expel a comedo by means of a 
watch key, etc., is often followed by the development of an acne 
lesion at the spot. 

Pathologically acne is an inflammation of the sebaceous glands. 
The inflammation begins either in or around the gland. One 
or several glands may be involved. The character of the lesion 
is determined by the activity and intensity of the process ; inflam- 
matory infiltration around the gland outlet giving rise to the 
smaller papules, and, when more extensive and periglandular 
as well, to larger indurated papules and tubercles; and, when 
suppurative action ensues, to the pustule. If the suppurative 
action is abundant the small dermic abscess results, and when 
intense, deep-seated and involving several glands, the large 
dermic abscesses are formed (Stelwagon). 

The diagnosis of well-developed acne presents few difficulties. 
We often meet with cases, however, where only a few imperfectly 
developed lesions are present, and where the affection may 
easily be mistaken for others of a widely different character. 
The age of the patient, the seat of the lesions, their chronic char- 
acter and their inflammatory nature must be taken into account. 
The acneform eruption caused by tar may be recognized usually 
by the smell of that substance and its presence in the follicles, 
giving the appearance of numerous black points differing in 
appearance from comedones. In the eruption caused by brom- 
ine and iodine (see Dermatitis medicamentosa) the lesions are apt 
to be larger, of a brighter and more acutely inflammatory nature, 
and, when well-developed, the lesions tend to coalesce and to form 
elevated, inflammatory areas covered with characteristic sebaceous 
crusts. Acne often closely resembles the papular and pustular 
syphilodermata, and great care must be taken to avoid mistakes 
in diagnosis. The history, the absence of syphilitic lesions on 
other parts of the body than those commonly affected by the erup- 



ACNE. 405 

tion of acne, the uniform distribution of the lesions, those of syph- 
ilis tending to group, all serve to denote the presence of acne. When 
syphilis occurs on the forehead, or in one or two lesions on the nose 
alone, without any history whatever, as I have sometimes seen it, 
it is extremely apt to be taken for acne, and great caution must be 
exercised in coming to a decision as to the nature of the affection 
in a case seen for the first time. Severe cases of acne are some- 
times taken for variola, but this can hardly occur if a careful 
examination is made into the general symptoms and history of 
the eruption. Sycosis also must be distinguished from acne. 
The treatment of acne is both constitutional and local. In 
order to treat a case of acne with any hope of success, we must 
first ascertain the causes which have operated in bringing it 
about. The foundation of the successful treatment of acne lies 
in the knowledge of its etiology. The patient should be carefully 
examined regarding every organ and every function. The habits 
of life, the surroundings, the occupation of the patient, should all 
be known to the physician, who should also study the case well, to 
discover, if possible, what is the exact cause or group of causes of 
which the acne eruption is the expression and result. External 
treatment, although in the light of recent advances in the eti- 
ology of the disease of much more importance than formerly, will 
rarely accomplish a cure, and internal measures must therefore 
be employed in almost every case. From what has been said 
under the head of etiology it will be perceived that in general the 
patient's health must be looked after and the system rendered 
more resistant to the invasion and spread of the disease. If 
anaemic, tonics are required, among which iron and arsenic are 
prominent; if the uterine functions are not regularly performed, 
these must be regulated; if dyspepsia exists, this must be com- 
bated by diet, regimen and the remedies appropriate to the 
condition. Constipation is a frequent concomitant with acne, 
and its removal is necessary to a cure. Acidity of the stomach, 
flatulence, coated tongue, are ordinary symptoms, and these, 
together with irregular and perverted appetite, are constantly 
met with in connection with the affection under consideration. 



406 DISEASES OF THE SKIN. 

If constipation exist, saline or vegetable laxatives should be 
prescribed in sufficient quantity to open the bowels once or twice 
in the day. An occasional mercurial, as blue pill or a compound 
cathartic pill, may be prescribed in some cases. The following 
pill has proved useful in my hands: 

1$. Pil. hydrarg., 

Ext. colocynth comp., aa gr. iiss (.15) 

Pulv. ipecac, gr. ss. (.03) M. 

Fiat in pil. No. j. 

Two or more of these pills are 'o be taken at bedtime, fol- 
lowed by a saline, as a wineglass of Hunyadi water in a goblet 
of plain hot water before breakfast the next morning. They 
are not, of course, to be taken habitually. 

The "mistura ferri acida" mentioned under eczema is likewise 
a valuable medicine 

Crocker suggests the following: 

1$. Ext. cascara sagrada liq. (B. P.), rrpc-xx (0.55-1.12) 

Tinct. nucis vomicae, nyvij-x (0.^8-0.55) 

Aq. menth pip., ad foj. (32. ) M. 

Sig. — Three times a day. 

The natural mineral waters are used with good success in 
acne. The Hathorn and Geyser springs of Saratoga, the Ger- 
man, Hunyadi Janos and Ofener Racoczy, Arpenta and other 
cathartic waters are of use, the dose, of course, varying with the 
amount of constipation present. 

There are many cases of acne, however, which depend upon 
some general derangement of the system, the " scrofulous taint," 
anaemia, etc., and these must be treated quite differently. Cod- 
liver oil will in many cases be found a very efficient curative 
agent, particularly when the lesions are indurated and tend 
to extensive multiplication over the trunk as well as the face, 
with the formation of numerous abscesses. The compound 
syrup of the hypophosphites is likewise of benefit in these cases, 
as is also the extract of malt, which may be employed in some 
instances to replace cod-liver oil when this is found to disagree. 



ACXE. 407 

The bitter and ferruginous tonics are occasionally called for 
in this class of cases, and the mineral acids are often of value. 
The following formula will be found useful in indurated acne 
with a tendency to the formation of abscesses, occurring in 
cachectic and scrofulous individuals: 

R. Quiniae sulphat., gr. viij ( 0.5) 

Acid, sulphuric, dil., rqx ( 0.6) 

Ferri sulphat., gr. xxxij ( 2. ) 

Magnesii sulphat., oiij ( 12. ) 

Tinct. zingiberis, f oij ( 8. ) 

Aquae, ad fS^iij- (256. ) M. 

SiG. — A tablespoonful in a tablespoonful of water, with a teaspoonfu 1 
of cod-liver oil floating in it, morning and evening. (T. Colcott Fox.) 

The following combination of iron with a mineral acid has 
sometimes proved of value when dyspeptic symptoms with 
anaemia coexist with the eruption of acne: 

R. Tinct. ferri chlor., 

Acid, phosphoric, dil., aa. . . . f§j (32.) 

Syrupi limonis f§ij. (64.) M. 

SiG. — A teaspoonful in a wineglass of water thrice daily, after meals. 

Among tonics arsenic stands first, sometimes appearing to 
act almost as a specific in anaemic cases. It may be given con- 
veniently in the form of Fowler's solution, in two to four minim 
(0.10-0.22) doses, gradually increased until the limit of tolerance 
is reached, and then dropped a little below this and continued for 
a considerable period. The following formula is a favorite with 
me; it combines the arsenic with iron: 

R. Liq. potassii arsenitis, f oij ( 8.) 

Vim ferri, ad f§iv. (128.) M, 

Sig. — A teaspoonful in water, after meals. 

I may say here that iron does not agree with some acne patients. 
As Dr. Fotheroill says, iron does not a^ree with ''bilious'' 
people. Instead of arsenic, mercury may be given. Dr. R. 
W. Taylor prefers the following formula: 



408 DISEASES OF THE SKIN. 

1^. Hydrarg. bichloridi, gr. j ( .06) 

Ammoniae muriat., gr. vj ( 0.40) 

Tinct. cinchonae comp., f giij (96. ) 

Aquae, fgj. (32. ) M. 

SiG. — Ateaspoonful in a wineglassf ul of water three times a day, an hour 
after meals. 

The dose here is the thirty-second of a grain (.002), which 
may be increased every ten days until in general the limit of 
toleration is reached. The effect of this treatment begins in 
about two or three weeks. Of course, it is not to 'be understood 
that syphilis is suspected in the cases in which mercury is 
recommended. It is simply as a tonic alterative. In cases 
when it may be desired to combine mercury and arsenic, Dr. 
Taylor recommends "De Valangin's solution," liquor arsenici 
chloridi, which can be given in connection with the bichloride 
of mercury. The dose of this solution is the same as that of 
Fowler's solution. The sulphur mineral waters, as those of 
Richfield, and the White Sulphur of Virginia, etc., have a 
reputation for beneficial influence in acne. I am inclined to 
believe that there is something specific in the effects of the 
waters themselves, though much of the good effected is gained 
by the pure air and general tonic effect of the surroundings. 
Hygiene, in the form of fresh air, exercise, cold bathing, and a 
sojourn in the country or by the seashore, will now and then 
effect what medicines may fail to do. It should be added that 
the seashore life occasionally is found to disagree with acne 
patients, bringing out the eruption in great abundance. Inquiry 
should be made before sending patients to the seashore, and 
they should be directed to change at once if the climate should 
prove unsuitable. 

The local treatment of acne is of great importance, the more 
so in the present state of our knowledge regarding the important 
part played by the organisms which induce inflammation and 
suppuration, especially so with regard to the choice of remedies. 
There is perhaps no skin disease in which so many local applic- 
ations have, at one time or another, been recommended. Used 
with discretion a few will suffice, but the great number of formulae 



ACNE. 409 

extant serve only to confuse the practitioner in search of an 
appropriate topical application. For this reason only a selec- 
tion of those ordinarily used is here given. 

The external treatment of acne may be either soothing or 
stimulating. In a small number of cases there is much heat, 
redness, and acute inflammation present, and here mild washes 
and bland ointments, such as those to be given under the treat- 
ment of eczema of the face, will best answer. 

When the case is a mild one and there is not too much irrit- 
ation, a medicated soap* containing sulphur, salicylic acid, 
ichthyol, or a small percentage of bichloride of mercury, may be 
employed to cleanse the surface and remove some of the oily 
and epithelial debris, after which a saturated solution of boric 
acid in alcohol of 96 may be sopped on or applied on compresses 
to the lesions. The parasiticidal effect of this remedy upon 
the purulent lesions is quite marked. Sometimes the more 
recent lesions may be aborted by means of this or similar applic- 
ations. 

Bathing the affected parts with hot water is usually of advantage 
and may be practiced twice daily, once when washing with 
medicated soap and once without. Immediately after the hot 
water applications the borated alcohol may be employed, or 
if a somewhat more active application is needed or can be borne, 
the folio wing lotion may be employed : 

I£. Hydrarg. bichlor., gr. vj-xij( 0.4-0.8) 

Alcoholis, f 5iss ( 6.) 

Aquae destillat., ad fgiv. (128.) M. 

This may be diluted with water at first and gradually made 
stronger. The patient should be warned against its possible 
irritating effects, and also with regard to its influence upon 
metals, as rings, etc. It should not, of course, be employed 
with sulphur in any form. 

Another formula often used is the following: 

* The medicated soaps devised by Eichoff are those which I find most con- 
venient. They are well made, and' although their therapeutic activity is not 
great, they form useful adjuncts to treatment. 



4IO DISEASES OF THE SKIN. 

1$. Hydrarg. bichlor., gr. iv ad viij ( 0.25-0.50) 

Tinct. benzoini, ttjxxx ad f 3 j ( 2.-4.) 

Emuls. amygdalae amarae, . . ..ad f5iv. (128.) M. 

A combination of bichloride of mercury with sal ammoniac 
is often employed, which is composed of 1 part each of chloride 
of ammonium and bichloride of mercury in 200 parts of emul- 
sion of bitter almonds. The following is a convenient combin- 
ation : 

J$. Hydrarg. bichlor., 

Ammonii chloridi, aa gr. iv ( 0.25) 

Aquae destillat., £§iv. (128. ) M. 

(Brocq.) 

Sometimes sulphur preparations are serviceable, especially 
in more severe cases. One of the sulphur lotions most com- 
monly employed is the following: 

fy Sulphuris praecipitat., 5 j ( 4-) 

/Etheris, fovj ( 24.) 

Alcoholis, ad foiv. (128.) M. 

SiG. — Shake well before using. 

Among the compounds of sulphur the following are fre- 
quently beneficial, particularly in sluggish cases of acne : 

1$. Potass, sulphuret., 9j ( 1.3) 

Tinct. benzoini, f 5j ( 4- ) 

Glycerinae, f5iss ( 6. ) 

Aquae rosae, ad foiv. (128. ) M. 

Another prescription which I have often used with benefit 
is the following: 

1$. Potassii sulphuret., 

Zinci sulphat., aa 3ss ad oj ( 2.-4.) 

Aquae rosae, f§iv. (128.) M. 

The ingredients are each dissolved in one-half the water, forming clear 
solutions. They are then mixed, and a white precipitate falls, which 
is to be shaken up and applied to the face. 

This should be used in a diluted form at first and gradually 
made stronger. It is not suitable when the skin is irritable. 

When the skin is rather coarse and sluggish the face may be 
rubbed and washed every night with the soap known as "sapo 



ACNE. 411 

viridis," an imported soft soap, the use of which was introduced 
into this country from Germany. It is of the consistency of 
ointment, and contains a slight excess of caustic potash. The 
solution of this soap in one-half its weight of alcohol, known as 
"spiritus saponis kalinus,"* may be used instead of the soap 
itself, when a milder effect is desired. A small portion of soap 
or a few drops to half a teaspoonful of the spiritus saponis should 
be rubbed briskly over the affected skin for several minutes. 
It must be remembered that these are strongly stimulant prep- 
arations, and their chief use is to cause absorption when the 
lesions are sluggish and indurated. They should be washed 
carefully off after use, and the part covered with powdered 
starch or a small quantity of cold cream or some other bland 
ointment. If they make the skin harsh, their use should be 
suspended or stopped. When the sebaceous gland ducts are 
unhealthy and plugged up, and when comedones abound, the 
soapy applications, especially if combined with copious bathing 
with hot water, loosen and aid in pressing out the plug of inspis- 
sated sebum, and in bringing the glands back to a more healthy 
condition. The watch-key or the comedo-extractor may also 
aid here in pressing out the comedones present, although these 
must be used with caution to prevent irritation. Sulphur and 
its preparations are, as has been said, among the most valuable 
remedies in our possession for the treatment of acne in most of 
its forms. The following may be given as among the most 
eligible sulphur ointments with which I have had experience: 

1$. Sulphuris prascipitat., 5j (4-) 

Ung. aquae rosae, 

Petrolati, aa 5iv. (16.) M. 

Camphor may sometimes be added with advantage: 

1$. Sulphuris prascipitat., 5 j ( 4- ) 

Pulv. camphorae, '. gr. xx ( 1.3) 

Ung. aquae rosae, 

Petrolati, aa oiv. (16. ) M. 

* The Tinctura Saponis Viridis, U. S. P., intended as a substitute for this, is 
not so efficient. 



412 DISEASES OF THE SKIN. 

Indurated and pustular acne may sometimes be benefited by 
the application to each lesion of a drop of solution of the acid ni- 
trate of mercury, on the end of a sharpened match, followed by 
bathing with hot water. Puncture with the point of a fine bis- 
toury or with a lance especially designed for this purpose, is a 
good procedure in indurated acne with a tendency to the for- 
mation of abscesses. 

It is a good plan to follow the puncture of the pustular lesions 
of acne by the application of some parasiticide. A sharp stick 
wet with a solution of bichloride of mercury (i-ioo) or with a 
drop of pure ichthyol will be found to discourage pus formation 
and to prevent recurrence of the pustule. The indolent indur- 
ated inflammatory masses which show no sign of suppuration 
may often be dispersed by the application of a 10 to 25 per cent, 
salicylic acid rubber plaster. 

Medicated soaps, particularly bichloride and ichthyol soap, 
should be used to cleanse the surface after puncturing or scari- 
fication. 

Unna highly recommends the employment of ichthyol, in the 
treatment of acne. He recommends to wash the parts thoroughly 
morning and evening with ichthyol soap and then to rub in the 
following lotion : 

fy Ammoniae sulph. ichthyolat., gr. xij-oij ( 0.7-8.) 

Alcoholis (90 ), 

Athens, aa f3iv. (16. ) M. 

It is usually well to begin with the milder strength of ichthyol 
and gradually increase it. The application can usually be 
allowed to remain on over night. If found irritating, it can be 
removed after half an hour and the parts covered with a slight 
application of the following ointment: 

1$. Acid, boric, 5ss ( 2. ) 

Acid, salicylic, gr. x (0.6) 

Ung. zinci oxid., § j. (32. ) M. 

Unfortunately ichthyol discolors the skin and patients often 
object to its use on this account. 



ACNE. 413 

Naphtol has been recommended in rebellious acne. In mild 
cases Brocq employs an ointment containing eight grains (0.5) 
each of naphtol, camphor and resorcin, forty- five grains (3.) 
of sulphur, twelve grains (0.7) of sapo viridis, and five drachms 
(20.) of vaseline. This may be allowed to remain in contact 
with the skin all night. 

In extensive acne indurata with small abscesses, especially 
when the back is covered with numerous suppurating lesions, 
a system of disinfection of the surface should be employed. 
The patient should remain in a warm bath until the skin 
is thoroughly softened, and then a bichloride of mercury 
soap of some kind, or the compound soap of resorcin, sali- 
cylic acid, and sulphur (Eichojj), should be thoroughly rub- 
bed into the surface. The larger suppurating lesions should be 
opened with an acne lancet, the contents very gently expressed, 
and a small quantity of pure ichthyol should be introduced 
into the cavity on a small probe or sharpened stick. Too 
much pressure should be avoided in emptying the contents of 
acne pustules, as it is possible to press the virulent matter 
into the surrounding tissues and thus create new foci of suppura- 
tion. Some of the soapsuds may be left in contact with the 
skin, or an ointment containing ten to twenty grains (0.65-1.30) 
of salicylic acid, and a drachm (4.) of boric acid to the ounce 
(32.) of vaseline, may be gently applied. If there is any con- 
siderable amount of serous leaking, which may occur where 
many abscesses have been opened, a dusting powder composed 
of one part of boric acid to four each of oxide of zinc and starch 
may be dusted over the surface. 

Recently the X-ray treatment has been used in the treatment 
of acne and in some cases with brilliant success. The cases in 
which the X-ray is particularly indicated are those in which the 
glandular element is prominent and, particularly where there 
are large indurated lesions and abscesses. This plan of treat- 
ment should be entered on with some caution, however, and 
the process should be kept under careful control. At times 
the prolonged use of the ray results in the formation of countless 



414 DISEASES OF THE SKIN. 

small cicatricial pits at the openings of the sebaceous glands, 
presenting on the face a pock-marked appearance. In the 
hands of the skilled operator, however, very excellent results 
are obtained. 

The prognosis of acne should always be guarded. While 
by no means the desperate and incurable malady which it is 
sometimes said to be, by pessimistic or incapable practitioners, 
yet it often offers a stubborn resistance to treatment, and shows 
a marked tendency to relapse. The most extensively developed 
cases, moreover, are sometimes more amenable to treatment 
than those where half a dozen lesions alone represent the disease, 
and where the patient enjoys apparently good health. The 
question is, in the long run, one of time only, as a spontaneous 
cure sooner or later almost invariably occurs. If neglected, 
however, unsightly and disfiguring scars supervene in severe 
cases, and our efforts, therefore, should be unremitting to obtain 
a speedy cure, if possible. 

Now and then keloid follows as a result of pustular acne. 
This condition, though unsightly and disfiguring, aisappears 
spontaneously with the lapse of time, perhaps in three to twelve 
months. Treatment usually fails to hasten its disappearance, 
but see on this point under Keloid. 

ACNE VARIOLIFORMIS. 

Acne varioliformis is an affection characterized by lesions of a papulo- 
pustular type, discrete or grouped, occurring most commonly on the upper 
part of the forehead and scalp, sometimes on the extremities and other parts 
and leaving scars somewhat similar to those of variola. 

Various names have been given to this affection and to the small group 
resembling it. as acne necrotica, lupoid acne, jolliclis, hidradinitis suppurativa, 
small pustular scrofuloderm, etc. The disease is not to be confounded with 
that to which the French formerly gave the same name and which is allied 
to molluscum contagiosum. 

The eruption is usually rather scanty, sometimes not more than a dozen 
or so lesions. It first appears in the form of a minute macule or maculo- 
papule, scarcely rising above the surface. The lesions soon become more 
elevated, bright red at first, later a dull red and often pierced by a hair. 
The acme is reached in several days to weeks, when a slight pustulation or 



ACNE ROSACEA. 415 

crusting shows on the apex. This lasts some days and then the dried scale 
becomes detached, leaving a puckered red depression. 

The depression finally changes in appearance to that of a depressed cica- 
trix, pin-head to small pea-sized, rounded, clean cut, variola-like scar. 
The lesions may be discrete or grouped and sometimes aggregated or bunched 
together. 

The favorite sites are, the forehead, just at the edge of the hair and the 
scalp, but the eruption may occur over the back, on the arms and legs, etc. 
There are usually no subjective symptoms but occasionally itching is ex- 
perienced. 

The eruption is probably the result of microbic invasion. It is a destruc- 
tive inflammation of the pilo-sebaceous structures. It is probable that the 
disease is of tuberculous origin or at least a paratuberculosis. 

Acne varioliformis is to be distinguished from the pustular syphiloderm 
which it closely resembles. The latter, however, is more widely distributed 
and the pustule is deeper and with more pus contained in it. The lesions 
of acne are larger, show more inflammatory action and suppuration and are 
usually preceded by comedo. 

Treatment should be antiseptic; a 3 to 6 per cent, ointment of ammoniated 
mercury, or a 10 to 20 per cent, ointment of resorcin may be used. 

ACNE ROSACEA. 

Acne rosacea is a chronic, hyperaemic or inflammatory disease 
of the face, more particularly the nose, characterized by redness, 
dilatation and enlargement of the blood-vessels, hypertrophy, 
and more or less acne. There are two classes of cases: 1. 
Those in which acne papules and pustules form the most prom- 
inent symptoms, while bright red congestion, with some infil- 
tration of the skin, forms the background. 2. Those in which 
a sort of erythema or flushing is the first symptom, superadded 
to which occurs in chronic cases an enlarged and varicose condi- 
dion of the superficial cutaneous veins, with occasionally hyper- 
trophy of the nose. 

The first variety is in reality more closely allied to simple acne. 
It occurs, however, usually in older persons, not often showing 
itself in women before twenty-five or thirty years of age and in 
men not until an even more advanced period. While the nose 
is the chief seat of this form of acne rosacea, it is likewise fre- 



4i6 



DISEASES OF THE SKIN. 



quently encountered upon the cheeks and sometimes upon the 
forehead and chin. While the entire course of the disease may 
be chronic, it usually proceeds by acute exacerbations or attacks 
following some digestive, uterine, or other derangement. In 
the second variety, hyperemia, or flushing, is the earliest symp- 
tom, intermittent at first and noticeable only after exposure to 
a close atmosphere or following the use of alcoholic stimulants 




Fig. 79. — Acne rosacea. (Seu hypertrophica.) (Dr. Duhring's case.)* 



or a full meal. This hyperemia is passive at first; the nose is 
cold to the touch and sometimes shows slight seborrhcea. Grad- 
ually the redness grows more marked and permanent. If now 
the nose is examined, small tortuous blood-vessels can be seen 
ramifying in the skin of the affected part. The disease varies 
in intensity in different cases, from a slight blush to a marked 
deformity. The face and particularly the nose are the parts 

* Photographic Review of Medicine and Surgery, vol. ii, 1871-72, p. 32. 



ACNE ROSACEA. 417 

usually attacked. The course of this form of the disease is 
chronic, sometimes extending over years. The process usu- 
ally goes no further than the formation of swollen and tortuous 
blood-vessels, with diffuse redness, but sometimes hypertrophy 
of the connective tissue takes place, with grotesque enlargement 
and deformity of the nose, which becomes knobby, irregular in 
shape and may grow to enormous size. 

The causes of acne rosacea are various. It occurs both in men 
and women, but in the latter does not often tend to go beyond 
the first stages. In women also the disease is more prone to 
occur at two periods of life, at early womanhood and at the cli- 
macteric period. When occurring in young women, seborrhcea 
is apt to be present, and the disease appears to be due, in some 
measure certainly, to dyspepsia, anaemia, chlorosis, and men- 
strual difficulties. Sometimes the first variety occurs during 
pregnancy without any other sign of ill-health and in persons 
who seem perfectly robust. It usually goes away under treat- 
ment, but may return in later fife. When it occurs in later life 
it is apt to be more severe. In men the disease may occur at any 
period. In early life it is generally due to anaemia and debility, 
nervous prostration, and dyspepsia. In later life the use of 
spirituous liquors is often the cause, and, perhaps, nearly as 
often, dyspepsia in some of its forms. Habitual indulgence in 
alcoholic or malt liquors gives rise to this condition in various re- 
gions of the face. 

The first stage in acne rosacea is a hyperaemia, probably angio- 
neurotic, but in some cases in consequence of a seborrhoeic 
process. Persistent hyperemia results in permanent enlarge- 
ment of the blood-vessels and in some cases in a condition of hyper- 
nutrition which may lead to hypertrophy. The sebaceous 
glands become involved, nodules, first of a gelatinous, later of 
a fibrous character, and acne or acne-like lesions are usually 
superadded, either secondarily or as part of the pathologic 
process. In the markedly hypertrophic forms there is connec- 
tive tissue growth and enlargement of the glands. The walls 

of the blood-vessels may be thickened and surrounded by con- 

27 



41 8 DISEASES OF THE SKIN. 

nective tissue and some of the veins may in places resemble 
cavernous tissue. The nodular and pustular lesions strongly 
resemble those of ordinary acne but some observers are inclined 
to believe them different. 

The diagnosis of the second variety of acne rosacea presents 
no difficulties. In the first variety, however, where acneform 
lesions, pustules, sebaceous crusts, etc., predominate, the diag- 
nosis is not always plain. The tubercular syphiloderm of the 
nose and face, lupus vulgaris, lupus erythematosus and severe 
forms of eczema are most commonly confounded with acne ro- 
sacea. A reference to the description of these diseases will serve 
to indicate the differential characters. 

The treatment of acne rosacea depends upon the stage of the 
disease and upon its cause in the given case. Constitutional 
and local remedies are both used. The causes giving rise to the 
affection should be diligently sought for and removed, when 
possible. Uterine and menstrual derangements are to be looked 
after, the stomach and bowels kept in good order, and all hygi- 
enic measures used to improve the general health. Alcoholic and 
malt liquors are to be totally eschewed. Tea and coffee should 
be drunk in moderation and not strong. Inveterate tea drinkers 
are very apt to have red noses. Tea is often made to take the 
place of food, and gradually brings on a sort of dyspepsia peculiar 
to itself. The food should be of the plainest character. The 
general medical treatment is that of acne. Local treatment, 
however, is of the most value. Sulphur ointments, as in acne, 
may be used in the early stages, the following formula being a 
useful one: 

1$. Sulphuris prsecipitat., 3j-ij (4.-8.) 

Ung. aquae rosas, o j. ( 32.) M. 

Sometimes lotions are more useful. 

The following lotion, known as Lotto sulphuris cum traga- 
canthce, is one of the very best in the treatment of acne rosacea, 
as well as all forms of acne simplex in which the rosaceous ele- 
ment is prominent: 



ACXE ROSACEA. 419 

Lotio Sulphuris Cum Tragacantele. 
(" Kurnmerfeldt's Lotion.") 

ly. Sulphuris praecipitat., 5ij ( 8. ) 

Pulv. camphorse, . . . . gr. x ( 0.6) 

Pulv. tragacanth., gr. xx ( 1.2) 

Aquae calcis, 

Aquae rosae, aa f o i j • (64. ) M. 

This may be applied once to several times a day. 

Sometimes the wash seems to "draw" the skin and gives rise 
to an uncomfortable sensation. In this case the sulphur oint- 
ment mentioned just above may be applied in small quantity 
after each application of the wash. On the whole, I have gotten 
more benefit for patients out of this wash than any other, and 
I count it the best application in acne rosacea. It will not 
always do good, however, and we are sometimes driven to try 
other plans of treatment. Ichthyol washes of various strengths 
are often useful in acne rosacea. A wash of corrosive sublimate, 
of the strength of one-fourth grain (.015) to two grains (.12) to 
the ounce of alcohol, or corrosive sublimate ointment somewhat 
stronger, sometimes answers well in the first stage of the disease. 
Neumann and Hebra recommended mercurial plaster spread on 
cloths. George H. Fox suggests the employment of chrysarobin, 
as in acne. Of course, this is to be watched, lest the irritative 
effect of chrysarobin be produced. 

In the second variety of acne rosacea, where numerous well- 
defined blood-vessels can be seen coursing under the skin, the 
treatment must be somewhat different. Scarification in some 
form here offers the best chance of improving the condition of 
the skin. The dilated capillaries may be incised with a tine 
sharp knife, in the hope that adhesive inflammation may result, 
with the effect of closing the vessels. The plan which I follow 
by preference, however, is that of cross-hatching the entire sur- 
face involved, not at one sitting, but in a series of operations. 
The larger vessels, if such are present, may first be slit up, and 
then with a multiple-blade knife, such as that figured under lupus 
erythematosus, held like a pen in the hand, a series of parallel 
cuts are to be made extending to about one-sixteenth of an inch 



420 DISEASES OF THE SKIN. 

below the surface. These are then crossed by a similar series 
of cuts at right angles, and in some cases a third series of cuts 
may be practiced. As the object is not precisely the same 
as in the similar treatment of lupus, it is not necessary or desirable 
to hash up the skin by a number of successive incisions at various 
angles. To prevent cicatrices, it is indeed sometimes better to 
practice only a single series of parallel cuts at one sitting. It is 
usually desirable to benumb the surface before operating in this 
way, especially on timid or nervous persons, and this may be 
done by means of freezing. A small gauze bag filled with min- 
gled ice and salt will produce the effect desired, but this may be 
accomplished more readily by the use of a hand-ball atomizer 
charged with rhigolene, or with chloride of ethyl now generally 
obtainable in glass tubes provided with a stop-cock. 

The little operation completed, the parts may be bathed with 
cold water or tightly compressed with absorbent cotton until 
bleeding has ceased. Cold water compresses are to be applied 
subsequently, to control the bleeding. After this a bit of dry 
lint or some simple dressing may be applied for a few hours. So 
soon as the soreness has passed away, perhaps in a week's time, 
scarification may again be practiced. A number of scarifications 
are usually required, the treatment running over a number of 
months, and requiring patience on the part of both operator and 
patient. Eventually, however, success is attained by this method. 
The skin heals over without any scar, or with such minute cica- 
trices as are hardly worth notice, and a marked amelioration in 
the appearance of the nose is the result. Of course, there is a 
strong tendency to relapse. The closure of some capillary chan- 
nels naturally leads to the dilatation of those collateral, and thus 
new vessels appear as old ones are obliterated. Sooner or later, 
however, a marked impression is made, and a fair result may be 
hoped for, even in severe cases. 

The sulphur and tragacanth wash may be employed con- 
currently with the surgical treatment described; it tends to keep 
down the preliminary erythema. 

Another treatment consists in painting the affected parts once 



ACNE ROSACEA. 42 1 

or twice weekly with a ten- to twenty-grain solution of caustic 
potassa and following this by an emollient poultice. In cases 
where there is but little thickening, carbolic acid dissolved in 
three to four parts of alcohol may be painted on the part every 
second day. Hardaway recommends electrolysis, using a num- 
ber thirteen cambric needle inserted into any convenient handle, 
and connected with the negative pole of a galvanic battery. A 
sponge electrode is then connected with the positive pole. The 
needle is inserted sufficiently deep to enter the dilated vessel; so 
soon as this has been accomplished, the patient completes the 
circuit by taking the sponge electrode in his hand. So soon as 
the electrolytic action has been properly developed, the patient 
releases the sponge electrode, after which the operator withdraws 
the needle. Six to eight elements will generally suffice. If the 
vessel to be operated upon is a long one, several punctures must 
be made at suitable intervals of space. The needle may be 
inserted perpendicularly or in a line with the course of the vessel. 
Of late years I have employed the electro-cautery as in lupus. 
Though some scarring results the cure is more rapid than by 
any other form of treatment. In those rare and severe cases 
where knobby and gross deformity of the nose exists, decortica- 
tion with the knife is the only remedy. 

The prognosis of the first variety of acne rosacea, at least in 
the early stages, is favorable, and there are few affections of the 
face in which more striking and rapid results can be attained, up 
to a certain point, than in those cases of acne rosacea where there 
is a "red face" with numerous papular and pustular lesions, with 
little or no capillary dilatation. When, however, we have the 
second form to deal with, and especially when the disease has 
become thoroughly established, only thorough and- long-continued 
treatment will avail. Where the capillary enlargement is already 
marked, treatment beyond a certain point is, in most cases, 
little more than palliative; it may prevent further progress, but 
this is much, and patients should be encouraged to persevere, 
especially in the treatment by scarification. 



422 DISEASES OF THE SKIN. 

4. DISEASES OF THE SWEAT GLANDS. 
HYPERIDROSIS. 

Hyperidrosis is an habitual general hypersecretion of the 
sweat glands. The condition may arise in health from heat, 
muscular exercise, the ingestion of hot drinks, etc., and in fevers, 
phthisis, and certain affections of the peripheral, central, and 
sympathetic nervous systems as a symptom of more or less import- 
ance. Hyperidrosis may, moreover, occur as a substantive affec- 
tion, and looking at it from this point of view, it may be described 
as a functional disorder of the sweat glands consisting in an in- 
creased flow of sweat. It may vary greatly in degree, from an 
amount scarcely in excess of health to a profuse stansudation. 
The local form of the disease, which is by far the most common, 
may occur upon almost any portion of the body, but is more 
commonly encountered about the palms, soles, axillae, and gen- 
itals. It may or may not be symmetrical, and is sometimes con- 
stant, while at other times it is intermittent or paroxysmal. 
Numerous cases of unilateral sweating are on record. 

Hyperidrosis upon the palms and soles is sometimes excessive. 
From the palms it may be so profuse that the fluid will accumu- 
late in the hollow of the hand until it runs over the edge. Upon 
wiping off the secretion in these severe cases the skin is observed 
damp, and sodden. The flow appears to come from the whole 
surface. The soles show the disease to a still more marked degree 
at times, the soaked epidermis becoming macerated and peeling 
off, and leaving the tender skin exposed. The pain on walking 
is often so severe as to keep the patient off his feet. Hyperi- 
drosis of the sole is almost always accompanied by decomposition 
of the sweat, which gives rise to a peculiar penetrating odor 
(see Bromidrosis). 

Lesser* says that there is some connection between the condi- 
tion known as flat-footedness and hyperidrosis. Trendelenburg 
thinks that the connection is through the nerves; either there is 
some reflex action or there is a mechanical pressure upon the plan- 
er nerve. Permanent flat-foot, Lucke thinks, occurs in persons 

* Deutsche Med. Wochens., Nov. 2, 1893. 



HYPERIDROSIS. 423 

of a "venous habit," that condition which coincides with weak 
muscles, cold feet, and excessive perspiration. With muscular 
weakness the formation of varices may occur; not necessarily 
of the superficial veins, but of the deeper veins, with perhaps 
thromboses. In 189 cases of hyperidrosis pedum, of which 98 
were males and 91 females, Lesser found that 51 per cent, of the 
men and 27.4 per cent, of the women were flat-footed. Varicose 
veins were found in 40.8 per cent, of the males and 39.5 per cent', 
of the females. 

The immediate causes of hyperidrosis are not well under- 
stood. It appears in some cases to be hereditary. It affects 
the cleanly and the dirty, the sickly and the healthy alike, 
and is met with in persons of all ages and both sexes. In 
addition to diseases of the nervous system, debility, malaria, 
and occasionally functional or organic disease of the internal 
organs, as the heart and lungs, may give rise to hyperidrosis. 
The affection is aggravated by high temperature, and is usually, 
though not always, worse in summer than in winter. Excite- 
ment of any kind, physical or mental, increases the flow of 
sweat. 

The treatment of hyperidrosis must vary with the individual 
case. When the cause is proximately or exactly known, inter- 
nal remedies appropriate to the general condition may be 
employed with good effect. If there be debility, a general 
tonic treatment is indicated. Iron, quinia, strychnia, and the 
mineral acids, especially aromatic sulphuric acid, may be used 
with advantage. Atropia is the most efficient remedy, and 
may be used at first to gain time for the further investigation of 
a case, or to introduce other treatment; its effect is apt to be tem- 
porary, however. It may be given by the stomach in doses of 
2-9-0 to -^q grain (0.0003-0.0012) dissolved in water, three times a 
day, until the physiological effects are produced. Or, in some 
cases, the hypodermic use of the drug may be found advisable, 
in the same dose, only with more caution. Pilocarpine has been 
highly recommended by some writers. Tincture of jaborandi, 
in doses of five to ten minims every second or third hour, or the 



424 DISEASES OF THE SKIN. 

muriate (or nitrate) of pilocarpine, in pill form, in the dose of 
2V grain (0.03) at similar intervals, may be prescribed. 

Local treatment in hyperidrosis is particularly useful, and, 
in some cases, may alone be required. Patients are apt to use 
too much water, particularly warm water, in washing the parts 
too frequently. The parts affected should be washed as rarely 
is possible — only when they are really dirty. Formalin soap may 
be used in bathing. They should be wiped, however, from time 
to time, with a damp cloth, and immediately dried witha soft 
towel, without friction. Various dusting powders, as starch, 
lycopodium, magnesia, and oxide of zinc, or the same with the 
addition of half a drachm of salicylic acid to the ounce, may be 
used. The following combination is useful: 

1$. Pulv. acid, salicylic, 

Pulv. zinc. carb. praecip., 

Pulv. magnesiae-ustae, aa 5iv (16.) 

Pulv. amyli, 5xv (60.) 

Pulv. talci, oxx. (80.) M. 

The powder should be removed and renewed so soon as it 
becomes moist and caked. Chloral in powder, in the proportion 
of one drachm (4.) to one ounce (32.) of starch powder, is one 
of the most efficient of all these powders. They are ordinarily 
only serviceable in mild cases. Slight cases of hyperidrosis may also 
often be cured by the use of juniper tar, carbolic acid and sulphur 
soaps. Lotions containing alcohol, alone or with the addition 
of some astringent, will be found useful. The following is a 
convenient formula : 

1$. Acidi tannici, 5 j ( 4-) 

Alcoholis, f oviij. (256.) M. 

SiG. — Use as a lotion. 

Salt baths are sometimes found serviceable. Tincture of 
belladonna, diluted or in full strength, may be employed, its 
constitutional effects being guarded against. Weak solutions of 
chloral, permanganate of potassium, and salicylic acid have been 
employed with success. In hyperidrosis of the palms and soles, 
washing with carbolic acid or juniper tar soap may be followed 



HYPERIDROSIS. 425 

by the application of the following ointment, spread upon cloths, 
and kept in place with a bandage : 

1^. Ung. picis, U. S. P., 

Ung. sulphuris, U. S. P., aa oss. (16.) M. 

In obstinate and severe cases, especially when the soles of the 
feet are affected, Hebra's treatment is the best. It is as follows: 
The parts having been cleansed with soap and water, the following 
ointment is applied: 

1$. Emplast. diachyli 

Olei olivae, aa oiv. (128.) M. 

The plaster is to be melted, and the oil added and stirred until 
a homogeneous mass results. 

Pieces of muslin or cotton cloth are to be cut to the size of the 
parts, and the ointment spread on thickly and applied. Lint, 
smeared with the ointment, is also to be placed between the toes 
(or fingers) so that every portion of the skin may be completely 
covered with a layer of the ointment. The dressings are to be 
bound down closely by means of a bandage. The cloths are to 
be changed twice in the twenty-four hours, when the parts are 
not to be washed, but simply rubbed dry with lint and a starch 
dusting powder after which new dressings are to be applied in 
exactly the same manner. This treatment is to be continued 
from one to several weeks, according to the severity of the case. 
Even when the disease is on the soles, the patient may be per- 
mitted to walk about in loose shoes. At the expiration of eight 
or ten days the parts are to be rubbed with the dusting powder 
and the dressings discontinued. The powder should be used 
for several weeks longer. Usually the sweating tends to lessen 
and gradually disappear after two or three weeks from the begin- 
ning of the treatment. A repetition of the course in severe cases 
is sometimes necessary before attaining a complete cure. I have 
sometimes obtained a good result with a 5 per cent, solution of 
chromic acid. 

Of course, the patient must give up his occupation while under- 
going this treatment — a sacrifice of time which is impossible in 



426 DISEASES OF THE SKIN. 

many cases. When, however, circumstances will permit, the 
treatment just prescribed will succeed when milder measures, 
however, faithfully applied, have failed. 

The prognosis of hyperidrosis depends somewhat upon the 
state of the patient's health, the duration and locality of the 
disease, and its extent. Many cases are easily cured, while others 
are extremely intractable. The ability of the patient to follow 
the treatment must also be considered, as careful attention to 
the directions given is essential to a cure. 

ANIDROSIS. 

Anidrosis is a functional disorder of the sweat glands, consist- 
ing in a diminished and insufficient secretion of sweat. It some- 
times occurs in connection with ichthyosis. (See Ichthyosis.) 
In rare cases an individual ceases to sweat entirely at times. 
In these cases the health is greatly impaired, and much suffering 
may ensue, especially in warm weather. The disease in this 
form is very rare. In the treatment every effort should be made 
to increase the activity of the skin. Hot or cold baths, steam 
baths, and frictions may be employed. Pilocarpine would seem 
to be indicated, but I do not know if this remedy has been em- 
ployed as yet. Of course, the general health should be looked 
after. 

BROMIDROSIS.* 

Bromidrosis is a functional disorder of the sweat glands, char- 
acterized by more or less sweating and an offensive odor. The 
sweating may be imperceptible or at times there is a condition 
of hyperidrosis to which an offensive odor is added. 

The body may give out a disagreeable odor as the result of 
ingestion of certain foods or medicines as onions, asafcetida, 
copaiba, musk, etc. In some cases the odor is the result of dis- 

*Cf. Monin, Sur les Odeurs du Corps Humain, Paris, 1885. Also, Ham- 
mond, The Odor of the Human Body as Developed by Certain Affections of the. 
Nervous System, New York Med. Record, vol. xii, 1877, p. 460. 



BROMIDROSIS. 427 

ease. In incontinence of urine a mousey odor is observed, in 
chronic constipation a fcecal odor. The ward smell of hospit- 
als comes from diseased body emanations. An infant ward 
may have a sour butyric acid odor while men's wards have an 
alkaline or ammoniacal odor. In rare cases the odor of the 
body is agreeable, resembling violets, banana, orris, etc. All 
these odors are, like those of typical bromidrosis, due to decom- 
position of fatty acids in the sweat. 

In practice bromidrosis of the hands and feet chiefly claim 
attention. As a general thing these occur in connection with 
hyperidrosis and therefore the treatment must be directed to 
both conditions. Many patients suffering from bromidrosis 
demand general tonic and hygienic treatment to raise the whole 
tone of the system. Aromatic sulphuric acid, twelve to twenty 
drops diluted with water three times a day, or atropine in doses of 
2W t0 tw grain (0.0003-0.0006) may be employed. Sodium sal- 
icylate in five to ten grain (0.3-0.6) doses has been used in some 
cases. Crocker recommends the following : J$. Pulv. cretae com. 
(B.P.), 5 y i (24.); pulv. cinamomii comp. (B.P.) 5ij (8-) ; sul- 
phuris precipitat, §i (32.). A teaspoonful of this to be taken 
twice a day. 

As regards local treatment, that used in hyperidrosis may be 
employed and in addition the following: 1$. Pulv. acid, salicylic, 
5j (4.); Pulv. aluminis ustae, 5 V (20.). M. Fox recommends a 
one per cent, solution of chloral or permanganate of potassium. 
Thin found in bromidrosis pedum that the moisture was alkaline 
and swarming with bacteria. He recommends that the stock- 
ings should be changed twice daily and that they should be placed 
in a jar containing a saturated solution of boric acid. They 
may then be dried and worn again, the odor having disappeared. 
Cork insoles should be worn through the day and soaked in 
boric acid solution through the night. In bromidrosis of the 
axilla formaline soap may be employed, or sponging with pure 
alcohol followed by inunction with a ten per cent, oleate of mer- 
cury ointment. 

Tschappe recommends the following: 



428 DISEASES OF THE SKIN. 

1$. Zinci sulphat., 

Ferri sulphatis aa §ij (62. ) 

Cupri sulphat., §ss ( 16. ) 

Betanaphtol., gr. ij-x ( 0.12-0.60) 

Thymol, gr. iv-x ( 0.25-0.60) 

Acidi hypophosphorici gr. ij-x ( 0.12-0.60) 

Aquae destillatae. Oj. (480. ) M. 

Of course, medicated soaps should be used in bathing the parts. 
Formaline soap, tar, salicylic, boric and sulphur soaps are all 
useful. The patient should be cautioned not to. take hot baths 
or sponge with hot water which favors excessive sweat secretion. 

CHROMIDROSIS.* 

Chromidrosis. An affection of the sweat glands in which 
the secretion poured out is colored, being usually blue or bluish- 
black. The so-called red and yellow chromidrosis is usually 
rather a parasitic growth on the hairs. 

In chromidrosis the quantity of sweat secreted is always in- 
creased. The affection occurs chiefly in hysterical women and 
usually affects the face, paticularly the lower eyelids, the chest, 
abdomen, the scrotum (in the few cases reported in males), the 
arms, and th e feet. It commonly appears in an* intermittent 
manner, following emotional excitement, or without appreciable 
cause. t The sebaceous glands are also involved in some cases 
and a black sooty oil may be wiped off. In a case under my 
care the patient "blushed blue" at times but after the "blush" 
had passed away bluish-black oily matter could be wiped off the 
skin. 

The pathology of chromidrosis is very imperfectly understood. 
The blue color has been said to be due to the presence of a phos- 
phate of iron (Scherer), to a compound of cyanogen analogous 

* For a full discussion of this subject with references, see the author's article 
on "Diseases of the Sweat Glands" in Twentieth Century Practice of Medicine, 
vol. v, New York, 1896. 

fHechelin {Sajous' Annual, 1895) reports the case of a boy ten years of age 
who displayed blue chromidrosis on the nose following a contusion. Exercise or 
emotion caused the color to show more distinctly as a blue perspiration. The 
coloring matter dissolved in chloroform and showed irregularly crystalline forms 
under the microscope. It appeared to be some derivative of indigo. 



HLEMATIDROSIS. 429 

to pyocyanine (Schwartzenbach), to a microbe, to a microscopic 
fungus, to indican, or Prussian blue (Bizio, Apjohn, Foot, etc.). 

Some observers have supposed this form of chromidrosis to 
be merely a simulated affection. I think, indeed, that some cases 
have been feigned, but the majority are unquestionably genuine. 

The treatment should be stimulating and astringent. The 
following ointment will be found useful: 

1$. Acid boric, gr. x 

Acid salicylic, gr. xv 

Ung. aquae rosae, o j- M. 

The customary treatment for hyperidrosis will also prove use- 
ful in severe cases. A general tonic treatment will usually be 
found indicated. 

HiEMATIDROSIS. 

This affection, known also as bloody sweat, ephidrosis cruenta, 
sudor sanguinosa, dia pedes is, etc., is a hemorrhage from the un- 
broken skin through the orifices of the sweat ducts. There is 
no such thing as an actual pouring out of blood as a secretion 
of the sweat glands, the hemorrhage in question probably oc- 
curring from the plexus of blood-vessels surrounding the glands 
into the ducts of these glands. 

The affection, 'though excessively rare, is so striking as to 
attract universal attention, and, consequently, records of its 
occurrence are found, not only in medical, but also in histor- 
ical works. A shallow skepticism, denying all extraordinary 
phenomena not coming within its own immediate observation, 
had, at the beginning of the century, swept aside all accounts 
of sweating blood as fabulous. More accurate observation has 
of late years established the fact that, under certain conditions, 
blood, in a more or less pure condition, may exude from the ori- 
fices of the sweat glands. The mechanism by which this exuda- 
tion takes place has not as yet, however, been satisfactorily 
explained, nor is it likely to be explained until we know much 
more, both of the physiology of the sweat secretion and of the 
circulation of the blood. A hemorrhage takes place from the 
capillary plexus about the gland coil and into the gland duct, 



430 DISEASES OF THE SKIN. 

but whether this is the result of passive dilatation, increased 
blood pressure, alteration in the structure of the vascular walls, or 
in the composition of the circulating fluid, cannot, in the present 
state of our knowledge, be positively stated. The process has 
some points of resemblance with that which goes on in purpura 
(see Purpura). 

As regards the appearances presented to the eye, these vary in 
different cases reported. Sometimes blood oozes or spurts from 
the uninjured and unchanged skin. At other times an erythem- 
atous patch first forms, or a thin scale, which is later lifted up 
by the sanguineous exudation beneath. In some cases a milia- 
ria-like, vesicular eruption precedes the diapedesis. 

Haematidrosis may occur in either sex, and among those appa- 
rently in the enjoyment of good health as well as among those 
who belong to "bleeder" families, or who are in a low state of 
vitality. In many cases the affection occurs in connection with 
" vicarious" or disordered menstruation. At other times it may 
occur as the result of an impoverished condition of the blood, or 
from sudden and strong moral impressions, as fright, anguish, 
etc. At times fever with high blood pressure precedes the effu- 
sion, while at other times a state of depression with slow pulse 
ushers in the phenomenon. Occasionally the affection is one of 
a number of symptoms connected with purpura. 

The diagnosis of the disease presents no difhculty, excepting 
in those cases in which simulation may be suspected. 

The treatment of the disease must in many cases be purely 
empirical, and be directed by circumstances. When, however, 
there are indications of increased excitement and vascular tension, 
the abstraction of blood by a vein or some other method of reduc- 
ing blood pressure is called for. Closely allied to haematridrosis 
is the curious affection known as stigmata. (See Feigned Dis- 
eases of the Skin.) 

Tears of blood are sometimes observed. Such cases have been 
reported by Damalix, Hasner, and Brun. {Med. Record and 
Weekly Med. Review, about i89o- , 92.) In these cases the eyes 
filled quickly with the bloody tears, the sanguineous character 



URIDROSIS. 431 

of which was demonstrated by microscopical examination. This 
affection is to be carefully distinguished from hemorrhages depen- 
dent upon orbital or conjunctival disease, such as polypoid con- 
junctival vegetations developed in the culs-de-sac of the conjunc- 
tiva. Genuine bloody tears are quite independent of any ocular 
or conjunctival disease, and their appearance is irregular. No 
apparent cause leads to their effusion. In some cases the escape 
of the tears is unattended by pain, in others the patient experi- 
ences pain in the forehead, the eyebrow, and at the root of the 
nose, or a sensation of pruritus, formication, or heat in the eye- 
lids. These morbid sensations persist only a few moments and 
cease with the appearance of the tears; the escape of the 
tears continues only a few minutes and the quantity of sanguin- 
eous lachrymal secretion varies from a few drops to a wineglass- 
ful. The phenomenon is usually intermittent, sometimes 
regular, but almost always transitory and attended by hemor- 
rhages from various cutaneous or mucous surfaces. Sanguin- 
eous lachrymation usually occurs in anaemic individuals, in those 
inclined to haematophilia and in hysterical women. 

URIDROSIS. 

Uridrosis is the name given to an excretion from the sweat 
glands containing the elements of the urine, especially urea. 
It appears as a colorless or whitish, saline, crystalline deposit, 
or coating, looking as if flour had been sprinkled upon the sur- 
face. The deposit can be scraped off with a knife, and is seen, 
under the microscope, to present minute crystalline spiculae. 
The disease is very rare. In most of the cases reported, partial 
or complete suppression of the renal function with disease of the 
kidneys and uraemic poisoning were present. 

PHOSPHORIDROSIS. 

Phosphorescent sweat has been observed in a few rare cases. It has been 
noted in the later stages of phthisis, in miliaria and in persons who have 
eaten putrid fish. The skin and sometimes the body linen becomes lumin- 
ous in the dark. It is probably due to the presence of photogenic bacteria 



43 2 DISEASES OF THE SKIN. 



SUDAMEN. 



This affection, also known as miliaria crystallina, shows itself 
in the form of minute, pin-point to pin-head size, clear, or pearly 
vesicles, closely crowded together, but never confluent, occurring 
usually on the trunk, especially on the neck, chest, and abdomen, 
though they may appear anywhere. They form rapidly, do not 
enlarge after the first few hours, get well in a few days, unless 
fresh crops appear, which may keep up the eruption for weeks. 

The lesions are the result of the sweat being unable to escape, 
owing probably to an accumulation of epithelium at the orifice 
of the duct, when the sweat function is in abeyance, as in fevers ; 
then, when the secretion is restored, especially by a "critical 
sweating," the fluid, being unable to escape by a natural channel, 
is effused under the horny layer and forms a vesicle. (Crocker.) 
Robinson and Pollitzer have made careful and critical micro- 
scopic studies of the lesions. The treatment is essentially the 
same as that of miliaria, q.v. 

HYDROCYSTOMA. 

Hydrocy stoma is the name given to a non-inflammatory affection charac- 
terized by discrete, pin-head to pea-sized, shining, translucent, somewhat 
deep-seated, persistent vesicles appearing on the face. 

The lesions occur generally in considerable number, single, grouped, or 
occasionally crowded together. They are rounded or ovoid, translucent, 
solid-looking, tense, shining, whitish or light yellowish projecting vesicles. 
They have a somewhat thick covering and show no tendency to rupture. 
The deeper seated lesions look like boiled sago grains. There are no ob- 
jective inflammatory symptoms in spite of the fact that the affection is 
classed as inflammatory. Hydrocystoma is apt to appear in summer. The 
lesions long remain unchanged but finally tend to dry up and disappear. 
The affection is often connected with excessive sweating. 

Pathologically the lesion is a cyst-like formation of the duct of the sweat 
gland. The process does not affect the sebaceous glands nor the hair fol- 
licles. Hydrocystoma is to be distinguished from milium, sudamen, adenoma 
of the sweat glands and vesicular eczema. 

The treatment consists in puncturing the lesions and applying an astrin- 
gent dusting powder. 



MILIARIA. 433 

GRANULOSIS RUBRA NASI. 

This rare affection occurs chiefly among children and is confined to the 
front and sides of the nose, although it has occurred on the upper lip, cheek 
and eyebrow. At first sight it looks like lupus. The part is of a bright 
red color, diminishing in intensity towards the sides of the nose and fading 
into the surrounding skin. Pin-point to pin-head-sized, deep red or brown- 
ish-red specks and papules are scattered over the surface. There is no dis- 
position to coalesce. The papules gradually develop into pustules and some 
dry up. There is always hyperidrosis of the affected area, the sweat appear- 
ing as droplets. The disease pursues a chronic course but apparently dis- 
appears with the approach to adult age. The affection appears to be a 
chronic inflammation originating in the vessels around the sweat apparatus. 

Treatment has hitherto seemed of little avail, though linear scarification 
has been suggested. 

MILIARIA. 

Miliaria vesiculosa, or rubra, says Crocker, has the same 
relation to sudamen as acne vulgaris has to comedo. Inflam- 
mation occurs in the gland as a consequence of retention of the 
sweat secretion, vesicles arise in great numbers upon the trunk, 
especially upon the back, but they may also come upon the face 
and limbs. The lesions are acuminate in form, whitish or yel- 
lowish in color, and situated on a raised red base. The vesicles 
run an acute course, drying up in a day or two and terminating 
in slight desquamation. The affection may come to an end in a 
few days, or may last some time, depending upon the persistence 
of the cause, usually hot weather or excessive clothing. It is 
very common among infants, especially in summer. There is 
a good deal of prickling or itching as a general thing. 

Miliaria papulosa is the affection formerly known as lichen 
tropicus, or "prickly heat." It manifests itself in the form of 
minute red, acuminate, discrete papules closely crowded to- 
gether, with vesicles or vesico-papules interpersed. The erup- 
tion comes out suddenly over large areas and is accompanied 
by excessive sweating and intolerable prickling and tingling. It 
is said to differ from M. vesiculosa in that the inflammation 
produces the obstruction to the sweat secretion instead of vice 



434 DISEASES OF THE SKIN. 

versa, as in the former disease. It is essentially a tropical dis- 
ease, though in a milder form often met with in our hot American 
summers. The disease may run on into eczema. 

The treatment of miliaria includes removal of the cause when 
this is possible, that is, keeping the patient cool and lightly clothed. 
Cool baths and saline diuretics are usually to be recommended. 
Vinegar and water, dilute lead- water, black wash, or some sooth- 
ing and astringent lotion, such as is recommended under eczema, 
may be employed. Solution of sulphate of copper, ten grains (0.65) 
to the ounce, (32.) may also be employed. It is a favorite remedy, I 
understand, in Cuba and the West Indies. Astringent powders, 
as bismuth subnitrate, oxide of zinc or kaolin, are also useful. 
The camphor powder described under acute eczema will often 
relieve the pricking and burning. Ointments are out of place. 
In the severe forms of the tropical variety, I should think that 
tincture of belladonna in two-drop (0.10) doses, or sulphate of 
atropia, in -^to grain (0.0003) doses, pushed to its physiological 
effect, might prove useful. I have never had an opportunity to 
try this treatment, as the milder local measures mentioned 
always suffice in our climate. 

HYDROADENITIS SUPPURATIVA. 

Hydradenitis suppurativa, known also as " hydradenitis destruens sup- 
purativa,"* is a rare disease of the sweat glands, characterized by the appear- 
ance of one or several deep cutaneous shot-like nodules, which gradually en- 
large to the size of a pea, undergo softening and suppuration, with subse- 
quent discharge and cicatrization. 

The disease, when well marked, may occur in the face or neck, but when 
the lesions are scanty in numbers or single the axilla, genitalia, nipple or 
anus is more apt to be the seat of the disease. When fully developed the 
shot-like lesions redden, suppurate at one or more points, give exit to a drop 
or two of pus, blood or a glairy yellow fluid, and then dry up leaving a de- 
pressed scar. The disease is probably of microbic origin. It is not to be 
confounded with acne and small sluggish furuncles Treatment is the same 
as for acne varioliformis. The disease is apt to last for years. 

* Pollitzer, Jour. Cutan. Dis., 1892, p. 9, gives a full review of allied forms with 
literature. 



favus. 435 



CLASS IX. PARASITIC AFFECTIONS. 

A. DISEASES DUE TO VEGETABLE PARASITES. 

FAVUS. 

Tinea favosa or favus is a vegetable parasitic disease of the 
skin, characterized by pin-head to pea-sized, friable, cup-shaped, 
yellow crusts tending sooner or later to form mortar-like masses. 

The affection first appears as a diffused or circumscribed super- 
ficial inflammation, with slight scaling, followed by the appearance 
of one or several pin-head-sized, pale yellow crusts seated 
about the hair follicles, which develope into the characteristic 
lesions of the disease, raised, sulphur-yellow cups, which can 
be detached from the skin underneath, having a moist, excoriated 
surface. The cups are friable and can be powdered between 
the fingers. They sometimes aggregate into masses. Usually 
each cup has a hair running through its center. When the 
disease is extensive, ulceration may exist under the crusts. It 
is usually situated in the scalp, but the nails and skin generally 
may be attacked in rare cases. When the nails are attacked 
they become thickened, yellow, opaque, and brittle. Favus pos- 
sesses a peculiar odor like musty straw, or like the smell of mice. 
The disease gives rise to some, but not to excessive itching. 

When favus has existed in the scalp to a severe degree and 
for a long time, a cicatricial condition with permanent baldness 
may ensue. It is a chronic disease. Situated in the scalp, 
it requires most energetic treatment to dislodge it, and is very 
prone to relapse. It is a rare disease. 

Favus is due to the invasion of the cutaneous structures, espe- 
cially the epidermal portion, by a vegetable parasite, the achorion 
Schoenleinii. The parasite consists of mycelium and spores and 
occurs in such abundance in the "cups" that it is easily dis- 



43 6 



DISEASES OF THE SKIN. 



tinguished under the microscope. The spores are usually rounded 
or ovalish. The mycelium is composed of narrow, apparently 
flattened tubes or threads, sometimes chain-like, which ramify 
in all directions without definite arrangements and are of vary- 
ing width and length. For purposes of examination a small 
fragment of the sulphur-yellow crust is placed on a slide with a 
few drops of liquor potassae and a cover-glass is placed upon it 
and gently pressed down to dissociate the elements. After 




Fig. 80. — Achorion schonleinii. (X5°° diameters.) 



standing a few moments, examination with a power of 300 to 500 
diameters will show the fungus, as described, in great abundance. 
According to Robinson, the parasite first obtains a lodgement 
in the funnel-shaped depression in the epidermis through which 
the hair shaft emerges upon the surface. It grows luxuriantly 
in the upper part of the hair sac and insinuates itself on all sides 
between the superficial layers of the epidermis. When it 
reaches a short distance on all sides of the follicle mouth, it 



TINEA TRICOPHYTINA. 437 

breaks the looser layers and appears on the surface, giving 
rise to the familiar cup-shaped bodies. 

The achorion invades the hair shaft but not to the extent 
that the ring-worm fungus does. The nutrition of the hair is 
interfered with by the mechanical pressure of the growth upon 
the papilla. The hair falls out and eventually in many cases 
the papilla atrophies and a new growth becomes impossible. 
Favus of the scalp results in baldness far more frequently than 
does ring- worm. The diagnosis of favus is usually easy; the 
peculiar yellow cups and the odor are commonly present, and 
even where the shape of the cups has been lost by suppuration 
or broken down by treatment, a patch of characteristic color can 
usually be seen here and there. The mousy odor is almost always 
perceptible, and most cases can be diagnosticated by this alone. 

In the treatment of favus of the scalp the hair is to be cut as 
short as possible, after which the crusts are to be removed with 
poultices,' or applications of olive or almond oil, and soap and 
hot water, as in pustular eczema of the scalp. After they have 
been removed, the scalp, in severe cases, will show pits and depres- 
sions, with atrophy, baldness, or areas of superficial ulceration, 
resembling the effects of syphilis. Depilation is then to be 
practiced by means of a pair of flat-bladed forceps, especially 
made for that purpose, or by other means. A small patch should 
be cleared each day. Immediately after depilation a parasiticide 
should be applied, and there is none better than a saturated solu- 
tion of sulphurous acid. Sulphur ointment, alone or with tar, 
may also be employed. Yellow sulphate of mercury, half a 
drachm (4.) to the ounce (32.), or chrysarobin ointment of the 
same strength, cautiously used, may also be used with benefit. 
The disease is, of course, contagious, and precautions must be 
taken against its transmission, particularly among children in 
families. 

TINEA TRICOPHYTINA. 

Tinea tricophytina, or ringworm, is a vegetable parasitic dis- 
ease of the hair follicles, hairs and smooth skin. There are 



438 



DISEASES OF THE SKIN. 



two distinct forms of fungi which may produce ringworm, the 
Microsporon Audouini, or small spored fungus, and the Tri- 
chophyton megalosporon, or large spored fungus. Of the latter 
several varieties are recognized.* The microsporon appears under 
the microscope chiefly in the form of a large number of round 
spores, irregularly grouped or massed about the follicular por- 
tion of the hair. Mycelial threads, 
large and branching, are also seen 
chiefly within the hair proper. After 
dividing and sub-dividing they ter- 
minate on the outer surface of the 
shaft in fine filaments, at the ex- 
tremities of which are the spores, 
which in this fungus are external. 
The microsporon is not found in 
ringworm of the beard and rarely 
in that of the body. It is never 
found in kerion. 

The tricophyton is composed of 
spores which vary greatly, but 
which, as a rule, are considerably 
larger than those of the micro- 
sporon. They are frequently 
cuboidal, oval or irregularly 
rounded; but their chief character- 
istic lies in the arrangement in lines 
or chains extending up and down 
the hair shaft. The mycelium is 
found without but never within the 
hairs. The tricophyton occurs in three varieties: the endothrix, 
in which the spores occur wholly within ; the ectothrix, in which the 
spores are distributed wholly without; and the endo- ectothrix, in 
which the spores are partly within and partly without the hair. 
The endothrix, like the microsporon, is found chiefly in the ring- 
worm of the scalp in children. The lesions, however, are some- 

* This description is taken from the text-book of Hyde and Montgomery. 




Fig.8i. — Tricophyton (endothrix). 



TINEA TRICOPHYTINA. 



439 



what different from those of microsporon. The ectothrix and the 
endoectothrix apparently are derived either directly or indirectly 
from the domestic animals, and are responsible for the ring- worm 
of the body, of the beard and from all suppurating forms of the 
disease. Charles J. White found the microsporon in 139 out 
279 cases of ringworm examined. 

For ordinary, clinical, microscopic examinations the hair 
may be placed on a glass slide and a drop of liquor potassa poured 




Fig. 82. — Tricophyton. (T. circinata.) (X 500 diameters.) 



over it and then covered with a cover-glass with light pressure. 
Stronger solutions quickly disintegrate the hair, but weaker solu- 
tions, 5 to 10 per cent., require several hours to clear the field. To 
stain the fungus the Morris- Calhoun method is as follows: 
The hair is first washed with ether to remove the fatty debris; 
it is then put for one or two minutes in the Gram iodine solution, 
and after drying is stained for from one to five minutes in gen- 
tian-violet and anilin-water. It is again dried and treated for a 



44° DISEASES OF THE SKIN. 

minute or two with the iodine solution, and for an equal length of 
time in aniline oil containing pure iodine, after which it is cleared 
with aniline oil, washed in xylol and mounted in Canada balsam. 
Coarse, dark hairs and spores within the hairs require more time 
for staining than do fine, light-colored hairs and the fungus-ele- 
ments situated without the hair. 

The features, character and behavior of ring-worm vary con- 
siderably according to the part involved, whether it be the gen- 
eral non-hairy surface, the genito- crural parts, the scalp, or the 
bearded region. The symptoms and diagnostic characters may 
best be described under the general regional headings. 

RINGWORM OF THE GENERAL SURFACE. 

Ringworm of the general surface, or tinea circinata, is char- 
acterized by the occurrence of one or more circumscribed, cir- 
cular, variously-sized, inflammatory, squamous patches, occur- 
ring on the general surface of the body, accompanied by itching. 
The disease usually begins as a small, reddish, scaly, rounded 
or irregular-shaped spot, which in a few days assumes a circular 
form, healing in the center as it spreads on the periphery, which 
is usually papular, but may occasionally be made up of small 
vesicles. Sometimes the rings coalesce and form gyrate figures. 
The disease may attack any part of the body, and is transmitted 
by contagion from one part to another. In children who have 
ringworm of the scalp more or less ringworm of the body is 
almost sure to be found at one time or another. 

A rather rare form of ringworm of the body shows itself as a 
somewhat raised, inflammatory patch beset with crowded follic- 
ular papules, papulo-pustules or pustules. Usually but one or 
two areas are present, of 2 cm. to 5 cm. in diameter, rounded in 
outline and showing considerable infiltration and thickening. 
The patches usually occur on the buttock, forearm or back of 
the hand. In the latter locality it constitutes what Leloir de- 
scribed as "discoid suppurative perifolliculitis." * 

* Leloir, Sur un Variete Nouvelle de Perifolliculitis Suppurees et Conglomerees 
en Placards, Annates de Derm, et de Syph., 1884, p. 436. 



RINGWORM OF THE SCALP. 



441 



The hairs of the area drop out and occasionally a boggy, pseu- 
docarbuncular aspect is produced, somewhat resembling kerion 
of the scalp. 

Tinea cruris occurs in the genito-crural region and beginning 
like ordinary ringworm spreads rapidly, favored by the heat and 
moisture of the part, until a 
considerable area is involved. 
The disease resembles eczema 
very closely, but a slightly 
raised, sharply defined border 
may usually be distinguished. 

The diagnosis of ringworm 
of the body is usually not diffi- 
cult. The growth and charac- 
ter of the patch, the tendency 
to disappear in the center and 
to spread upon the periphery 
are characteristic. Psoriasis 
occurs in rings but the scales 
are more abundant and coarser 
and the distribution is quite 

Fig. 83. — Ringworm ot inflammatory 
different. (Set Psoriasis.) The kerion-type on back of hand. (Discoid 

circinate syphiloderm has fewer suppurative perifolliculitis. Leloir.) 
scales, a more dusky color and more infiltration. Eczema 
seborrhceicum as it occurs in rings on the sternal and inter- 
scapular region, resembles ringworm closely, but the scales are 
more adhesive and greasy, and the glandular openings are in- 
volved. Microscopic examination of the scales will determine 
the diagnosis in doubtful cases. 




RINGWORM OF THE SCALP. 



Ringworm of the scalp is characterized by one or more, usu- 
ally circular, variously-sized, more or less bald patches, covered 
with ashen-gray scales, with a "goose-flesh" appearance and 
numerous small, broken-off stumps of hair. Sometimes the dis- 



442 



DISEASES OF THE SKIN. 



ease is disseminated, when a search through the scalp will show 
black points scattered here and there, which are the stumps of 




p IO g 4 — Ringworm of the body and scalp in the same individual. 



diseased hairs broken off level with the scalp. Ringworm of the 
scalp is a disease of childhood, and is not met with in the adult. 



RINGWORM OF THE SCALP. 443 

It is highly contagious among children. Microscopic examina- 
tion shows the hairs filled with roe-like spores, infiltrating their 
tissue and rendering them highly brittle. 

The diagnosis of ringworm of the scalp is usually easy. The 
only disease with which it is liable to be confounded is alopecia 
areata,* but here the hairs fall out entire, leaving a smooth, ivory- 
like surface. Now and then squamous eczema of the scalp looks 
like ring- worm, but there are no broken-off hairs. 

The treatment of the ringworm of the scalp is tedious and 
difficult, because it is hard to get the remedies down to the roots 
of the hair, where the fungus greatly flourishes. Of the great 
number of remedies constantly turning up almost all would be 
good if they could be gotten into contact with the fungus, but 
the best will fail if it cannot be made to reach the last and remotest 
spore in the deepest hair follicle. 

As a preliminary to treatment the hair should be cut short, 
scales should be cleansed from the scalp, and the diseased hairs 
should be pulled out by means of convenient forceps, immedi- 
ately after which the parasiticide should be applied. In boys, 
when the eruption is extensive, the scalp may be shaved from 
time to time. Daily depilation of diseased hairs is an exceed- 
ingly troublesome, but very necessary procedure. It may be 
greatly aided by the employment of Bulkley's depilating sticks 
composed as follows : 

1^. Cerae flavae oiij (12.) 

Laccae in tabulis, ! oiv (16.) 

Resinae, 3vj (24.) 

Picis Burgundicis, ox (40.) 

Gummi Samar, oiss. (48.) 

This compound is to be melted and moulded into sticks six 
to eight centimeters in length and one centimeter in diameter. 

When moulded for use, the end of the stick is warmed in a 
flame until it begins to melt and is then pressed down upon the 

* In exceptional cases the loss of hair in ringworm of the scalp is rapid and 
complete, the hairs not breaking off at the surface level but falling out complete 
("bald ringworm"). Such cases are difficult to diagnosticate, but the presence 
of ringworm at other points may usually be demonstrated. 



444 DISEASES OF THE SKIN. 

diseased patch with a slightly circular motion. In a few minutes 
when the gummy stick has cooled sufficiently it may be jerked off 
with a quick motion and will bring away a score or more of dis- 
eased hairs at once. Some practice is required to operate with- 
out giving unnecessary pain and in particular not to burn the 
patient by applying the stick to the scalp while too hot. 

As the hair invariably breaks off, depilation is incomplete. 
But by this means we remove a mass of the fungus and allow 
the penetration of the remedy more deeply than otherwise. 

Among local remedies, carbolic glycerine is one of the best. 
It may be applied to the diseased patches in strength varying 
from i in 8 to i in 3, according to the age of the patient, while a 
weaker lotion of the same should be rubbed in over the scalp 
generally to prevent drying of the scales and spread of the conta- 
gion. Laillier, as the result of an enormous experience at the 
St. Louis Hospital, in Paris, recommends solutions of corrosive 
sublimate, i to 300 to 1 to 1000. Of course, a certain amount 
of caution should be observed in the application of this remedy. 
Thin employs sulphur ointment, one drachm (4.) to the ounce 

(32-)- 

Iodized collodion, 1 to 30, has sometimes been employed 
with success. An ointment highly recommended by Alder 
Smith is the following: 

1^. Acid, carbolic, cryst., 
Ung. hydrarg. nitrat., 
Ung. sulphuris, aa oss. (16.) M. 

The ingredients are to be mixed without heat. This oint- 
ment may be used in children over eleven years of age. Under 
this age it is advisable to use a double proportion or even more 
of the sulphur ointment. This may be used once a day over the 
entire scalp, the patches themselves being rubbed twice a day. 
As made in this country, it is apt to be very soft, which is an incon- 
venience. In disseminated ringworm of the scalp, oleate of mer- 
cury (a five per cent, solution in children under eight years of 
age, and a ten per cent, solution in older children) may be used. 



RINGWORM OF THE SCALP. 445 

The oil is to be rubbed in nightly with a sponge mop, care being 
taken not to allow it to run over the face; a cap should be worn at 
night. When the scalp is very irritable and the application of 
any of these remedies causes inflammation and superficial crust- 
ing, the following ointment may be used with advantage: 

1$. Ol. cadini, 
Sulphuris, 

Tinct. iodini, aa. . . . oiss ( 6.) 

Acid, carbolic, n|xx-xl ( 1.60-3.2) 

Adipis benzoat., 3iv. (16.) M. 

In weakly children cod-liver oil, arsenic, and iron are often 
required, and should always be prescribed if the case seems to 
demand them, or if the eruption spreads from one place to another 
while under treatment. 

The prognosis of ringworm of the scalp should be guarded 
as to the time required to effect a cure. In cases of average se- 
verity, if there are several coin-sized patches of disease, and if 
the hairs are at all markedly involved, four months, at least, 
of careful treatment will usually be required to effect a cure. 
When the disease is disseminated a much longer time will be 
required. A cure should not be promised, unless all directions 
as to shaving, depilation, etc., are faithfully carried out. In 
cases where kerion forms, as the result of treatment, or in the 
course of the disease, a more rapid cure may be expected. 

Tinea kerion is an inflammatory and suppurative form of 
ringworm of the scalp. It shows smooth, yellow, reddish, or 
purplish patches, more or less raised, cedematous, and boggy. 
They are honeycombed and studded with yellowish, suppurative 
pits, the openings of the distended hair follicles deprived of 
their hairs, which discharge a mucoid, gummy, honey-like fluid. 
The lesions sometimes itch, burn, and pain. In severe cases 
baldness results. The condition sometimes supervenes to a mild 
degree during the treatment of ringworm of the scalp. The 
treatment is the same as for the latter, excepting that lotions 
of sulphurous acid may be added to the parasiticides above men- 
tioned. Alder Smith has suggested the artificial production of 



446 DISEASES OF THE SKIN. 

T. kerion by penetrating the hair follicles by a needle moistened 
with croton oil. This must be practiced with caution, and only 
over a small area, say a quarter of an inch square, at any one 
time, for fear of exciting too great inflammatory action. 

RINGWORM OF THE BEARDED REGION. 

Ringworm of the bearded region, or tinea sycosis, is not of 
such common occurrence as the disease on the scalp or general 
surface. 

Two types are observed, one superficial, and the other the 
deep-seated or nodular form. In the superficial variety the dis- 
ease begins very much as in the non-hairy regions, but the rings 
are not usually so typical in character. Commencing at one or 
more points in the beard the disease heals in the center as it 
spreads on the periphery and often encloses a rather large, irreg- 
ular area. Ringworm in this form does not show any tendency 
to pustulation but it may develop into the deep-seated f orm. 

The deep-seated variety begins on the surface, but soon in- 
volves the deeper structures and as a result more or less subcu- 
taneous swelling ensues and the affected parts assume a distinctly 
lumpy and nodular form resembling deep-seated furuncles or 
carbuncles. The nodules usually break down after a time and 
discharge at one or more of the follicular openings a glairy, glu- 
tinous, muco-purulent or purulent material which may dry to 
thick, adherent crusts. The eruption may involve the whole 
of the beard around the chin and neck, producing marked dis- 
figurement. It seldom involves the upper lip. 

The superficial variety of ringworm of the beard often closely 
resembles eczema seborrhceicum of this locality which is a very 
common affection. The tendency to form rings, or at least to 
spread on the periphery, is characteristic of ringworm and, of 
course, an examination of the scales will show the presence of 
ring- worm fungus. 

The deep-seated nodular form when fully developed can scarcely 
be mistaken for any other disease. In partly developed cases it 



RINGWORM OF THE BEARDED REGION. 



447 



sometimes looks like the nodular syphiloderm. The evident 
involvement of the hair follicles, the hairs being loose or having 
fallen out and leaving patulous openings, together with the pres- 
ence of the ringworm fungus abundantly in the hairs, will decide 




Fig. 85. — Rinj 



;\vorm of the beard, deep seated variety (tinea sycosis). 
(From a model by Baretta.) 



the diagnosis. This last feature also will distinguish singworm 
of the beard from ordinary sycosis. The latter is a more super- 
ficial, pustular disease and the hairs are adherent to their 
sheathes and extracted with some difficulty and pain. 

In the treatment of ringworm of the bearded region extraction 



448 



DISEASES OF THE SKIN. 



of the diseased hairs should invariably precede the application 
of remedies. The hair of the beard generally should be kept 
close clipped so as to admit careful inspection in order to fore- 
stall the development of new foci of disease. The remedies suit- 




Fig. 86. — Hair from tinea sycosis. 



able for other forms of ringworm are called for here but, in par- 
ticular, lotions of sodium hyposulphite 3j a d Sj (4. ad 32.) may 
be sopped on, followed by a 10 to 20 per cent, sulphur ointment as 
recommended by Stelwagon. Dilute solution of sulphurous 



TINEA IMBRICATA. 449 

acid may also be used. In some cases Stelwagon recommends 
the use of a corrosive sublimate lotion, from i to 3 grains (0.065- 
0.20) to the ounce (32.) followed by a 10 per cent, oleate of 
mercury, calomel or white precipitate ointment. I have found an 
ointment of pyrogallol, 3 ss ~j to 5j ( 2 -~4- to 32.) very valuable 
in some cases. 

TINEA IMBRICATA. 

This affection, known also as Burmese ringworm, Malabar itch, and by 
various other designations, is a vegetable parasitic disease peculiar to trop- 
ical countries. 

The disease begins at one or several points as a brownish, slightly raised 
spot which spreads at the periphery to almost half an inch in diameter, when 
the central part of the dry epidermis cracks, becomes detached centrally 
and leaves a border or ring with the epidermis curling up on the inner side 
As this ring increases in size on the outer edge a new lesion forms in the 
center so that when fully developed several concentric rings are seen. Sev- 
eral of such rings may become joined together forming irregular serpentine 
lesions and the whole surface may become invaded by the disease. The 
effect is like that of a surface of "watered silk." The disease is due to a 
vegetable parasite resembling that of ordinary ringworm but distinct from 
it. The treatment is that of ordinary ringworm, but the clothing should 
be sterilized or burned, as relapses are common. 

TINEA VERSICOLOR. 

Tinea versicolor is a vegetable parasitic disease, characterized 
by variously- sized and shaped furfuraceous, macular patches of 
a yellowish-fawn color, and occurring for the most part on the 
upper portion of the trunk. 

The disease begins by the formation of pin-head and split- 
pea-sized, yellowish spots, usually scattered here and there over 
the affected region. These grow gradually larger and coalesce, 
forming hand-sized and even extensive patches, with extremely 
irregular margins sharply defined against the sound skin. There 
may be only a few patches, or, on the other hand, the disease may 
be quite extensive. The patches are usually more or less scaly. 
The disease does not usually itch in cool weather but when the pa- 
tient grows warm and sweats, there is apt to be a good deal of itch- 
29 



45° 



DISEASES OF THE SKIN. 



ing. In some cases, there is never any itching. The chest and back 
are the parts usually and chiefly affected, the disease also spread- 
ing down the flanks, and over the buttocks, abdomen, and groins. 
The disease rarely extends above the shirt-collar, below the elbows 
or below mid-thigh. Practically, it is an affection of the trunk, 
which often presents a mapped appearance, owing to the pecul- 
iar and irregular configuration of the lesions. The disease usu- 
ally spreads slowly, and without treatment may continue for an 




Fig. 87. — Microsporon furfur. (X500 diameters.) 



indefinite period. Relapses are not uncommon, even when the 
treatment has been most judicious. 

The disease is due to the vegetable parasite known as the 
microsporon jurfur. The fungus consists of mycelium and spores, 
the latter being disposed in distinct groups or masses. The para- 
site luxuriates in the corneous layer of the epidermis, sparing the 
rete, hairs and true skin. 



TINEA VERSICOLOR. 45 1 

The diagnosis of tinea versicolor is not usually difficult. The 
seat of the disease is commonly upon the trunk alone, and, where- 
ever else it occurs, it is always to be found there. Vitiligo, 
chloasma, and the macular syphiloderm are the diseases with 
which T. versicolor is most apt to be confounded. In vitiligo, 
however, the patches are rounded and white ; it is the surrounding 
skin which is dark; in chloasma the face and forehead are the 
chief seats of the disease, and are rarely spared, while in T. 
versicolor the face is never attacked. The macular syphiloderm 
does not often occur in large patches and sheets, and it is not con- 
fined to the localities of T. versicolor; also, there are almost in- 
variably concomitant symptoms of syphilis. From all these 
affections T. versicolor is distinguished by its proneness to itch. 
Finally, a microscopic examination of a few of the scales, to which 
a drop of liquor potassae has been added, under a power of 350 
to 500, will show the peculiar and characteristic fungus, which, 
it may be remarked, is different from both that of ring- worm and 
that of favus. 

The treatment of tinea versicolor is simple, and, if thoroughly 
carried out, quite efficacious. The best plan is to anoint the 
affected parts with sapo viridis, well rubbed in daily, for a week, 
avoiding the contact of water. After a pause of forty-eight hours, 
a hot bath, with soap, is taken and the disease, if mild and recent, 
will be found to have disappeared. If some remains, the same 
process may be repeated until a cure is effected. Another excel- 
lent application is sulphite of sodium, in the form of a lotion, one 
drachm to the ounce of water. 

Whatever treatment is employed must be thoroughly applied. 
If a single patch is left untouched the whole disease may return. 
Two or three weeks usually suffice for a cure if the remedies 
have been well applied; but the patient should be inspected a little 
later, to see if the disease has begun to crop out again in some 
obscure point. From its nature T. versicolor is contagious. I 
have never been able, however, to demonstrate the fact of con- 
tagion in practice. 



45 2 DISEASES OF THE SKIN. 

ERYTHRASMA. 

Erythrasma is a vegetable parasitic disease characterized by reddish-brown 
patches, presenting in situations where there are moist and opposing sur- 
faces, as the genito-crural and auxiliary regions. 

The affection is of slow development, beginning in the form of small 
spots of a reddish-brown or orange-red color and usually in the genito-crural 
region. The spots grow and coalesce into sheets and confluent areas, but 
rarely go beyond the groins and axillae. There is little or no itching. 

The disease is caused by a vegetable parasite, the microsporon minutissi- 
mum, about one-third the size of the microsporon furfur and showing no 
groups of spores like the latter. 

Erythrasma is to be distinguished from tinea versicolor, which it closely 
resembles. It pursues a slower course, however, and does not show the 
same tendency to spread beyond its chosen areas. Tinea circinata is more 
inflammatory and pityriasis rosea more patchy and diffuse. A somewhat 
higher power of the microscope is required to detect the spores but these 
are characteristic. The treatment is the same as that of tinea versicolor. 

Pinta Disease.* A contagious affection of certain tropical countries 
characterized by the appearance of whitish, bluish-gray or blue, or even 
black, scaly spots appearing first most frequently upon the face or neck but 
developing also upon other exposed regions', as the forearms, hands, lower 
part of the legs and feet and upper part of the chest. The palms and soles 
are not invaded. Occasionally the mucous membranes are invaded. The 
disease spreads by extension and is sometimes after a long time accompanied 
by thickening and Assuring of the skin in the folds. It is due to a fungus of 
the aspergillus class. The treatment is that of the vegetable parasitic dis- 
eases. Perhaps iodine and chrysarobin are the best drugs to use. 

ACTINOMYCOSIS.! 

Actinomycosis of the skin is an affection due to the ray fungus, 
characterized by a sluggish, red, nodular, or lumpy infiltration, 
usually with a tendency to break down and form sinuses and 
most commonly involving the cervico-facial region. 

The usual situation of the disease is about the jaw, neck, and 
face. The organism finds entrance through the mouth, most 
frequently to the jaw through a decayed tooth. The first evi- 

*See Barbe, Annates de Dermatol, et de Syph., 1898, p. 985 (with a colored 
plate), and La Pratique Dermatotogique, T. i, p. 1900. 
fThis description is taken from Stelwagon, I. c. 



ACTINOMYCOSIS. 453 

dence is a hard, subcutaneous swelling or infiltration which 
may attain moderate or quite conspicuous dimensions, the over- 
lying skin soon becoming of a sluggish, dark red color. Soften- 
ing occurs sooner or later with the occurrence of sinuses oozing 
sero-purulent or purulent, sometimes sanguinolent fluid. Con- 
tained in the discharge are minute, friable, yellowish or yellow- 
ish-gray bodies composed of the fungus. The disease spreads 
until quite an area is involved with a nodular irregular mass of 
a bluish, red or red color with here and there openings from 
which oozes more or less discharge. The course of the affec- 
tion is slow. There are no subjective symptoms. 

The disease is due to the actinomyces or ray fungus. It is con- 
tagious by inoculation and is commonly contracted from cattle 
and horses and therefore is seen among those having to do with 
these animals. It is rare in this country. 

The actinomyces fungus consists of a central network mass 
of interwoven threads, from which the mycelia radiate like pro- 
jecting rays. The fungus is usually readily demonstrable, both 
in the discharge (the yellowish grains), and in the tissues. His- 
tologically the nodular and infiltrated mass is made up of granu- 
lation tissue, having a resemblance to that of round-celled sar- 
coma; in some instances epithelioid, giant cells and mast cells 
are to be seen. 

Actinomycosis is to be distinguished from syphilis, sarcoma, 
carcinoma, tuberculous affections, mycetoma, and phlegmon- 
ous inflammation. The presence of disease, particularly about 
the lower jaw, the history of infection, and especially the pres- 
ence of the peculiar yellowish bodies all help to make the diag- 
nosis likely. A m croscopic examination of the discharge or of 
the tissues would make the diagnosis certain. 

The prognosis of the disease is generally favorable, unless 
some part, as the orbit or some internal organ, is attacked. The 
treatment consists in the removal of the local lesions by curet- 
ting, etc., followed by strict antiseptic treatment. Iodide of 
potassium has been given internally with success in some cases 
while in others it has failed. 



454 DISEASES OF THE SKIN. 

MYCETOMA. 

This disease, known also as fungous foot of India, is an endemic affection 
occurring chiefly in India,* and characterized by swelling and the formation 
of tubercular or nodular lesions which tend to break down and form sinuses 
leading into the subcutaneous structures, and finally resulting in disintegra 
tion of the affected part. 

The disease usually occurs in one foot, more rarely in the hand or 
shoulder. Furunculoid swellings or tumors appear, blebs form on the sur- 
face which become the point of exist of sinuses, giving exit to whitish gran- 
ules or black, roe-like masses, mingled with a sanious discharge. 

The parasite finds entrance to the skin through some slight traumatism, 
as a splinter, etc. The organism is the actinomyces madurce consisting of 
mycelium of branching threads and hyphae and ovoid spores. There are 
two varieties, the black and yellow, and the small black and yellow gran- 
ules discharged from the sinuses are made up of masses of fungi closely re- 
sembling the ray fungus. 

Sections of the tissues involved show branching sinuses and cavities filled 
with a fatty or gelatinous substance, hard and dark in the black variety, 
soft and ochre-colored in the yellow. 

The disease maybe distinguished from actinomycosis by its origin, locality, 
clinical features, and finally by microscopic examination of the fungus. 

The disease pursues a chronic course sometimes lasting ten or twenty 
years, and leading inevitably to destruction of the parts involved. Surgical 
removal offers the only relief. Care should be taken to leave no trace of 
disease behind or recurrence may confidently be expected. 

BLASTOMYCETIC DERMATITIS.f 

Blastomycetic dermatitis is an inflammatory affection of the 
skin, due to the yeast fungus or blastomyces, and characterized 
by the appearance of papules or papulo-pustules which increase 
peripherally while flattening in the center so as to cover consider- 
able areas. The lesions when fully developed are covered with 
a crust, the removal of which shows a papillomatous surface. 

The disease begins as a papule or papulo-pustule which slowly 

*Five cases have been reported in this country, two by Hyde, Senn and Bishop 
and by Adami and Kirkpatrick, Jour. Cut. Dis., 1896, and three by Pope and 
Lamb, N. Y. Med. Jour., 1896, p. 386, Wright Trans. Assn. Am. Phys., 1898, p. 
471, and Arwine and Lamb, Am. Jour. Med. Set., 1899, p. 393. 

fSee the papers of Gilchrist, Johns Hopkins Hosp Rep., 1896, vol. i, p. 269; 
Hyde, Hektoen and Bevan, B. J. Derm., 1899, p. 261, and F. H. Montgomery, 
Jour. Am. Med. Assn., June 7, 1902, for full description and illustrations. 



pediculosis. 455 

spreads while flattening down in the center and showing a crust. 
The removal of this crust shows a papillomatous surface with, 
later, purulent deposits at various points. The border of the 
patch is elevated, reddish, usually of a deep red tinge and well- 
defined by moderate infiltration. In the older parts of a diseased 
patch healing may take place, the surface skinning over and 
exhibiting a thin atrophic or scar-like appearance. The affection 
has usually been observed in the back of the hand, face and 
lower part of the leg, but may occur elsewhere, new foci of dis- 
ease sometimes appearing at some distance. 

The disease is rare. It has usually been observed in men over 
forty. Investigations have disclosed the yeast fungus as the cau- 
sative agent. The histopathologic characters are in a measure 
similar to those found in tuberculosis verrucosa cutis, the bla- 
tomyces being found chiefly in miliary abscesses in the tissues. 

The disease is to be distinguished from tuberculosis verrucosa 
cutis, the vegetating syphiloderm and lupus vulgaris. The bor- 
der of the tuberculous lesion, however, has a deeper and more 
violaceous color and is less likely to be extensive. The syphilitic 
disease is more rapid in its development and shows much more 
purulent discharge. Lupus vulgaris is relatively slow in its 
course, with a more distinct ulcerative tendency and frequently 
rather tough, firm scarring. Microscopic examination alone, 
however, will in some cases decide the diagnosis. 

The treatment should include the internal administration of 
iodide of potassium which has in some cases proved valuable, 
but most reliance should be placed upon local measures. Anti- 
sepsis, curettage and the X-ray may be employed. 

B. DISEASES DUE TO ANIMAL PARASITES. 

PEDICULOSIS. 

Pediculosis (lousiness) is a contagious animal parasitic affec- 
tion, characterized by the presence of pediculi or lice, and the 
lesions which they produce, together with scratch marks and 
excorations, accompanied by itching. Three varieties of the dis- 



456 DISEASES OF THE SKIN. 

ease are encountered, which are designated, according to the 
locality affected, viz., pediculosis capillitii, pediculosis vestimen- 
torum, and pediculosis pubis, or head, body, and crab lice. 

Pediculosis always occurs as the result of contagion; a spon- 
taneous origin of the parasites is quite incredible. The pedic- 
uli do not bite, but are furnished with a sucking apparatus, 
which they insert into the mouth of a follicle, and obtain blood 
by the means of this. 

The diagnosis of pediculosis may almost always be made by 
finding the parasites, but these are frequently few in number in 
any given case, and must be carefully searched for, remembering 
in the case of each variety its special habitat. When the pediculi 
cannot be found, the location of the scratch marks offers valuable 
circumstantial evidence pointing to the parasitic character of the 
disease. In the scalp and pubis the presence of nits or ova may 
almost always be made out, and also at times in the seams of the 
clothing, and they, of course, are distinctive. The prognosis of 
pediculosis is always favorable, and when the directions are 
carried out faithfully, a speedy cure may be expected. 

Pediculosis capillitii is due to the presence of the Pediculus 
capitis, or head louse. It is the commonest form of pediculosis. 
The parasite is found on the scalp alone, the occipital region being 
the favorite seat. The lice are sometimes found in the scalp and 
sometimes on the hairs. The ova, or- "nits, " small whitish, pear- 
shaped bodies, glued to the hairs by the smaller end, some dis- 
tance from the scalp, resemble scales of epidermis. Head lice 
are usually met with among women and children of the poorer 
class, though they are sometimes found on persons of refinement, 
where they appeared to have been contracted on sleeping cars 
while traveling or in other accidental associations. The para- 
sites attack the scalp and give rise to considerable irritation, itch- 
ing, and consequent scratching. Effusion of serum, pus, and 
blood results from this, and the hairs become matted together 
in a crust. Lice, as a rule, cause more mischief in those who 
are poorly nourished and ill-cared for. The majority of cases 
of eczema in the back of the head, in the poorer class of children, 



PEDICULOSIS. 



457 



are caused by lice, and Dr. J. C. White has pointed out that, 
in children, when a characteristic form of eczematous eruption 
can be seen about the mouth, the nostrils, and the ears, the lobes 
especially, the diagnosis can almost certainly be made of pedic- 
ulosis capillitii. This eruption, in some respects, resembles that 
of impetigo contagiosa. When the affection has existed for some 
time there is a disgusting odor about the scalp; the patient 
loses sleep from the itching; the mind becomes harassed, and 
the general health may be more or less impaired. 

The best treatment for head lice is to saturate the scalp nightly, 
for several successive times, with kerosene, care being taken not 





Fig. 88. — Ova of pediculus 
capitis (nits) attached to hairs. 




Fig. 89. — Pediculus cap- 
itis, (female.) 



to allow the oil to trickle down over the face and neck, for fear of 
its causing excoriations. A nightcap is to be used, and the head 
washed with castile soap and warm water in the morning. When 
kerosene cannot be used, the next best thing is the tincture of coc- 
culus indicus. Where, owing to shortness of hair and the presence 
of eczema, ointments can be employed conveniently and profitably, 
that of ammoniated mercury, in the strength of twenty to sixty 
(1.30-4.) grains to the ounce (32.), wall be found useful. An 
ointment of one drachm (4.) of powdered stavesacre seeds to the 
ounce (32.) of lard is also a good remedy. The nits, which are, 
however, usually killed by the applications of kerosene, are to 



458 



DISEASES OF THE SKIN. 



be removed by repeated washings with soda or borax washes, 
soft soap, vinegar, dilute acetic acid, or alcohol. Greenough 
thinks the following formula best in the majority of cases : 

1$. Acid, carbolic, gr. xv-xxv ( 1.-1.60) 

Petrolati., §j. (32.) M. 

This not only destroys the lice, he says, but sterilizes the ova. 
Persian insect powder (pulvis pyrethri) may also be used. The 
scalp should be dried of moisture and the powder should be dusted 
or blown through a tube or blower, sold in the shops for such 
purposes. A muslin cap should then be placed on the head 
and retained for an hour or so, after which the scalp should be 

washed out with vinegar and water 
to kill the nits, which are not de- 
stroyed by the powder. It is seldom 
or never necessary to cut the hair. 
In children it is often more con- 
venient to do so, but in adults it is 
an unnecessary sacrifice, which may 
be avoided by patience in relieving 
the hair of pediculi and nits. The 
head coverings should be destroyed 
or thoroughly disinfected by baking 
or boiling. 

Pediculosis vestimentorum, or 
lousiness of the body, is produced 
by the pediculis corporis — body, or, 
more properly, clothes louse — which 
lives in the garments, and thence makes predatory excursions 
upon the skin. It is very similar to the head louse, but is 
considerably larger and somewhat longer in proportion to its 
breadth, and shows a blackish tinge on the back. Body lice 
are apt to be found along the seams of the clothing, partic- 
ularly where this comes in close contact with the skin, as 
about the neck, shoulders, waist and buttocks. As they move 
over the surface or attack the skin, they give rise to intensely 




Fig. 90. — Pediculus vestimento 
rum. (female.) 



PEDICULOSIS. 459 

disagreeable, itching sensations. As the parasites multiply, 
the itching becomes so violent that the distress is almost unendu- 
rable; the scratching is generally severe, and long and streaked, 
or short and jagged scratch marks, with blood crusts and pig- 
mentation, are characteristic features of the disease. On close 
inspection, the primary lesions, which are minute, reddish puncta, 
with slight areola, may be seen marking the points at which the 
parasite has drawn blood. 

The chief seats of the lesions are the back, especially about 
the scapular region, the chest, abdomen, hips, and thighs. When 
the affection has lasted for months and years general pigmenta- 
tion may occur, as the result of long-continued irritation and 
scratching. Children are very seldom attacked. The disease is 
one of want, poverty, and neglect. It sometimes occurs among 
the better class of people, particularly in the aged; but even here it 
will be found to have been brought about by want of personal care. 

Occasionally one is consulted by persons suffering from what 
may be called pediculophobia. This is, in reality, a mental 
affection or a neurosis of the skin. Itching can hardly be pres- 
ent in the ordinary sense of the term, but undoubtedly there 
must be some perversion of sensation. On examination the skin 
is found to be absolutely free from symptoms of disease. Such 
cases require to be managed with much tact. A local placebo 
with attention to the general health may be used in some cases 
with success. 

To get rid of body lice, a hot bath, with soap, should be 
taken, while the clothing is being heated in an oven or boiled, or 
when this cannot be done, ironed along the seams with a hot 
iron, to destroy the parasites with their ova. After the bath, 
inunctions are to be practiced with an ointment of powdered 
stavesacre seeds, two drachms (4.) to the ounce (32.), digested 
in hot lard and strained. A lotion of carbolic acid is useful to 
allay the itching: 

1^. Acidi carbolici, oiij ( 12.) 

Glycerinae, f o j ( 32.) 

Aquae, Oj. (480.) M. 



460 DISEASES OF THE SKIN. 

The following is even better in old cases: 

J\. Acidi carbolici, 5ij ( 8.) 

Potass, caustic, 5j ( 4-) 

Aquae, fgiv. (128.) M. 

The potash is dissolved in water, and slowly added to the 
carbolic acid in a mortar. The wash should be much diluted 
before applying. 

The disinfection of clothing should be carefully carried out, 
and must be repeated again after a few days, if it has not been 
entirely successful. 

Pediculosis Pubis. The pediculus pubis, or crab louse, though 
usually found on the pubis, is also encountered in the axillae, 
sternal region, and beard, in the male, and in children, especially, 
upon the eyebrows and eyelashes. Crab lice are found adhering 

closely to the hairs at the surface of the 

^1^15^ skin; their strong claws permit them to 

$s take such hold of the hairs that they 

%^^^^S^\^ are often detached only with difficulty. 




The ova are very much like those of 
the pediculus capitis, but smaller and 
^ISPIHIC^ are f° un d firmly attached to the hairs. 

They infest adults chiefly, and give 

Fig. qi. — Pediculus pubis. • ,-■ ,1 ,1 

1 rise to the same symptoms as the other 

pediculi. Although almost always contracted in sexual inter- 
course, yet they now and then find their way to the pubis of 
persons who are entirely unable to account for their presence. 
They may occur from sleeping in berths of sleeping cars, etc., 
or from water closets. The amount of irritation caused by their 
presence varies with the individual; it is, as a general thing, 
comparatively slight. 

Crab lice may be removed by the application of tincture of 
cocculus indicus, of full strength or diluted, or by any of the 
ointments or lotions used in the other forms of pediculosis. Mer- 
curial ointment, the well-known popular remedy, is no more 
effectual than the others, and makes a nasty mess. Its use, in 
general, is to be avoided, in favor of any of the other applica- 



ANIMAL PARASITES OF MINOR IMPORTANCE. 461 

tions. Covering the pubis for a few moments with a cloth satur- 
ated with a small quantity of chloroform will kill all living crab 
lice instantly. The hair may then be washed with hot soapsuds, 
sponged with vinegar, and combed. The sponging with vinegar 
may be continued once or twice daily for a week, to get rid of all 
nits. When patients will permit, shaving the pubis shortens 
the cure greatly. 

ANIMAL PARASITES OF MINOR IMPORTANCE ATTACKING 

THE SKIN. 

Cimex lectularius, or bed-bug, is an insect of universal distribution. It 
simply goes to the skin for nourishment, puncturing it, injecting, in all prob- 
ability, an irritating fluid, and sucking blood. An inflammatory papule or 
wheal results, sometimes purpuric in character, which may last for days. 
Several punctures are sometimes made in a group which are seen covered 
with a blood crust. The legs, especially in the neighborhood of the ankles, 
are a favorite point of attack. Sometimes considerable irritation and pustu- 
lation is caused by scratching. The condition at times resembles urticaria, 
but may be distinguished by the hemorrhagic tendency, central puncture and 
persistence of the wheals not seen in urticaria. 

Pulex irritans, or flea, is of general distribution over the inhabited world 
but is perhaps more common in tropical countries. The irritation caused 
by it varies in different individuals. The most usual lesion is a small ring- 
like erythematous spot with a minute, central hemorrhagic point marking 
the place of attack. It has sometimes been mistaken for purpura. In 
some persons the lesion is barely perceptible and gives rise to no discomfort. 
In others urticaria-like lesions with more or less persistent itching,, tender- 
ness and a burning feeling may result. The puncture of the insect leaves 
a minute, central hemorrhagic point which is characteristic from a diagnostic 
point of view. 

Washes of camphor, thymol, menthol or carbolic acid or a combination 
of these will give relief and by their odor discourage the visits of the insects. 
Travelers, especially women, find a small piece of camphor suspended 
around the neck in a bag a sometimes efficient preventive. Stel wagon 
says that small bags containing powdered pyrethrum stitched inside the 
clothing at various points will produce an atmosphere repugnant to fleas. 

Ixodes. Of the ixodes or ticks there is a great variety, of which the 
ixodes bovis is a type. These parasites are transmitted to man from the 
domestic animals, as the cow, sheep, etc., or are picked up in the woods 
They are practically leathery bags with lancet-like mandibles and suction 



462 



DISEASES OF THE SKIN. 



apparatus. When the bag is empty the legs can be employed in locomotion, 
but when filled with blood the tick is a pea-sized, red ball with the legs ex- 
tended and lying flat upon the surface. It fastens itself to the skin by two 
small claw T s extending on each side the suction apparatus. The tick does 
not inject venom and therefore does not give rise to burning or itching sen- 
sations. It may be detached from the skin by dropping a little essential 
oil, as oil of cloves, upon it, or benzine or ordinary kerosene. If the tick 
once becomes imbedded in the skin it cannot be pulled out. The body sep- 
arates from the head, leaving the latter under the skin, where its presence 
gives rise to inflammation and suppuration. 





Fig. 92. — Ixodes bovis. 
(Riley.) 



Fig. 93. — Dermanyssus gallinae. (Chicken 
louse.) 



Closely allied to the ixodes by nature, although different in appearance, 
is the argas, or dove -tick, found in dove cotes and pigeon roosts, from which 
it spreads to human habitations. This tick has its legs, as well as its mouth 
and suction apparatus, situated on the under surface, so that when attached 
to the skin it sometimes looks like a minute clam-shell closely adherent to 
the surface. Unlike the ixodes, this form of tick injects venom, and thus 
becomes very irritating to the skin. Moreover, as it only remains on the 
skin while feeding and moves from host to host, it may be the means of 
transmitting disease. When the dove-tick invades a human habitation it 
may become a perfect plague. Unlike the ixodes it is nocturnal, and is apt 
to attack the uncovered parts. The effects of its venom are sometimes se- 
vere, giving rise, in persons subject to urticaria, to severe attacks of this af- 
fection or to localized oedema. 

Belonging to the acari is the dermanyssus gallince, or hen louse, found in 
hen-houses and dove-cotes. It is different from the argas, or dove-tick, in 
appearance and habits and is apt to occur in persons living close to hen- 
houses or having much to do with fowls. The eruption is a dermatitis from 
scratching and is very itchy. It is confined to the arms and legs. Carbolic 
washes or inunction with a mild sulphur ointment constitutes the treatment . 
Disinfection of the habitation of the fowls should, of course, be practiced. 



SCABIES. 



463 



Other parasites which attack the human skin for nourishment are the 
mosquito {culex anxijer), gnat {culex pipiens), and certain kinds of flies and 
other insects, which give rise to erythematous and urticarial lesions varying 
in intensity in different individuals, but usually being more more severe in chil- 
dren. Some insects, as bees, wasps, spiders ants, caterpillars, etc., only irrit- 
ate the skin inadvertently or on self-defense 

The remedies mentioned above, and, in addition, tincture of camphor or 
dilute ammonia water may be employed to mitigate the pain. A 2 or 3 per 
cent, solution of menthol, oil of eucalyptus, or tar oil may be spread upon 
the surface to prevent the attack of the insects just mentioned. 



SCABIES. 

Scabies, or "the itch," is a contagious, animal parasitic disease, a 
sort of eczema or dermatitis, caused by the presence of the acarus 



or sarcoptes scabiei in the skin. 



It is highly 



The 




Fig. 94. — Sarcoptes scabiei. (female.) Fig. 95. — Sarcoptes scabiei. (male.) 



female itch mite no sooner finds itself on the skin than it begins 
the work of burrowing, forming, just below the surface of the skin, 
a burrow in which the eggs are laid, the faeces deposited, and in 
which the itch mite lives. The male is said never to enter the 
skin, but to live upon the surface. After a time, a certain num- 



464 DISEASES OF THE SKIN. 

ber of young itch mites are hatched forth, all of which begin at 
once to take care of themselves, and to burrow. Thus, the early 
symptoms of the disease are caused by the irritating presence 
of these parasites at various points, and characterized by the 
formation of minute, more or less inflammatory, puncta, papules, 
and vesicles. Later, the burrows can be seen in the shape of 
more or less tortuous, beaded, yellowish or blackish lines, not 
thicker than a thread, and one-eighth to one-quarter of an 
inch in length. Later still, scratch marks, blood crusts, etc., 
show themselves, and the disease spreads day by day. 

The affection usually begins about the hands, and especially 
about the fingers. The wrists, the penis in men, and in women 
the mammae, are next involved. The other softer and more 
protected parts of the body are then invaded. The anterior fold 




Fig. 96. — The female acarus in its tunnel showing ova, evacua- 
tions and detritus. (After Kaposi.) 

of the axillae and the buttocks are very apt to be attacked. The 
lower limbs are generally spared, excepting the feet in children. 

Itching, oftentimes very severe, is a marked feature of the 
disease, increasing in severity with its extension. It is worse 
at night, when the patient is warm in bed. 

The cause of scabies lies, as has been said, in the irritating 
presence of the itch mite in the skin. It is so contagious that it 
may be conveyed by bedding or clothes, or even by a shake of 
the hand'. It is not a common disease in this country, occurring 
only in the proportion of one per cent, among all skin dis- 
eases. In Europe, on the other hand, the unwashed populations 
furnish a larger proportion of scabies than of any other skin 



SCABIES. 



465 



disease. The recent increased immigration of Italians, Poles, 
etc., has much increased the percentage of scabies in public 
clinics in our large cities. 

The "army itch," frequently encountered in closely quartered 




Fig. 97. — Scabies showing a favorite seat of the disease. 



armies, is a severe form of scabies. Other names are given to 
the disease, depending upon the real or supposed origin of groups 
of cases, as "Hungarian itch," "Polish itch," "Italian itch," 
"lumbermen's itch," etc. The affections formerly known as 



30 



466 DISEASES OF THE SKIN. 

"grocer's itch" and "baker's itch," on the other hand, are forms 
of eczema. 

The diagnosis of scabies is, as a rule, not difficult. The pres- 
ence of the burrow is sufficient to decide the matter, and this 
should be looked for in every suspected case. The mite itself 
may usually be extracted from the minute vesicle at the end of 
the burrow by the aid of the point of a pin or needle, but fail- 
ure to capture it need not be regarded as negative evidence in 
the diagnosis, for it requires a good light, sharp eyes, and some 
dexterity to succeed. The burrows must not be confounded 
with irregular lines of epidermis filled with dust or dirt. The 
resemblance is, at first sight, strong. In the majority of cases 
the burrows are only to be detected upon the sides of the fingers, 
or on the flexor surface of the wrists. The regions of the body 
mentioned as the favorite seat of scabies must be taken into con- 
sideration in making the diagnosis, and finally, it must be remem- 
bered that other affections may be concurrent with scabies upon 
the body. 

Once recognized the disease is, in most cases, easily cured. 
The great point is to use the applications in such a manner that 
the parasite may be destroyed without undue irritation of the 
skin, and, indeed, with relief to this condition. When the case 
is recent, a cure can be rapidly and easily effected, but when of 
old standing there is apt to be a good deal of eczema in connection 
with the scabies, and after the parasite is destroyed the eczema 
remains for treatment. The following ointment seems to cure 
the eczema while killing the itch mite: 

1$. Pulv. naphthol, 5j (4-) 

Ung. adipis, oj- (32.) M. 

On coarse skins sapo viridis may be used with the naphthol : 

1$. Pulv. naphthol, 5iss ( 6.) 

Saponis viridis, 3v (20.) 

Cretae alb. pulv., 5j ( 4-) 

Axungiae, ox. (40.) M 



ANIMAL PARASITES OF MINOR IMPORTANCE. 467 

A formula recommended by Stelwagon is; 

1^. Sulphur sublimat., 5iv-vi ( 16. -24.) 

Bals. peruvian, 5iv (16. ) 

Beta, naphtol, 5i-ij ( 4--8- ) 

Adipis benzoinat., 

Petrolati aa q. s. ad §iv. (128. ) 

I have used one or another of these prescriptions almost exclu- 
sively, for several years past, and prefer them above all others. 
Sulphur is the old standard remedy, and may be used in the form 
of ointment, ranging in strength from one to four drachms to 
the ounce, according to the tenderness of the skin. 

The treatment, whatever it be, should be preceded by a hot 
bath with soft soap, after which the ointment should be rubbed 
in, and allowed to remain. After seven days of treatment, 
an inunction being made daily, and the underclothing remaining 
unchanged, the patient should bathe and report for inspection. 
Too vigorous a course of treatment may give rise to a dermatitis, 
which will require weeks to cure. 

The prognosis of scabies is always favorable; a few weeks will 
suffice in average cases, but the irritation of the skin requires 
longer treatment to overcome. 

ANIMAL PARASITES OF MINOR IMPORTANCE PENETRA- 
TING THE SKIN. 

The leptus, or harvest mite, more properly termed trombidium or tetrany- 
chus, is of several varieties. As it is usually met with it is in the immature 
or "leptus" stage. The appearance is depicted in the accompanying cuts. 
As met with in the Middle Atlantic States the harvest mite is a minute, 
active, brick -red-colored, elongate pyriform creature with six long legs barely 
visible to the naked eye. It is found in the axilla, upon the scalp and on 
other parts of the body, and more frequently upon children than upon 
adults. It does not completely bury itself in the flesh but insinuates the an - 
terior portion of the body only beneath the skin, causing a small inflamma- 
tory papule. The little red mite encountered in the swamps and low 
grounds in Pennsylvania, New Jersey and Delaware, especially about black- 
berry bushes, is in all probability the same species. Duhring recommends 
sulphur ointment as a treatment for the parasites. Ointments of balsam of 
Peru may also be employed. 



4 68 



DISEASES OF THE SKIN. 



Pidex penetrans, "chigoe," jigger or sand flea, is found in warmer or 
tropical climates. It inhabits dwellings and frequented forests, attaching 
itself indiscriminately to men and beasts. The buccal apparatus of this flea 
is furnished with mandibles carrying reverted spines, so that when the pulex 
has penetrated the skin it is detached with some difficulty. It has a pro- 
boscis almost as long as its body. The impregnated female perforates and 
burrows into the skin and in the course of a few days becomes enormously 
enlarged. 

The feet, especially about the toe-nails, are the especial seat of the para- 
site, and persons going habitually barefoot are much more likely to be at- 
tacked. Itching is first experienced, then pain, while a tumor appears 
which soon suppurates. The "jigger" can be found bathed in the pus of the 




Fig. 98. — Trombidium 
Americanum (tick.) 
(Century Die.) 



Fig. 99. — Leptus irritans. 
(Century Die.) 



Fig. 100. — Six legged 
carvae of leptus Jau- 
tumnalis. (Kuchen- 
meister.) 



abscess. It is smaller than the common flea, being about one and three-tenths 
millimeters in length. Unless treated the abscess tends to grow worse and 
gangrene has been known to result. The treatment is early removal by 
means of a needle, care being taken not to break the sac-like body and set 
free the ova. Strong carbolic acid should then be applied. 

Filaria Medinensis, sometimes called Dracunculus, or Guinea-worm dis- 
ease is an affection chiefly of tropical countries, caused by a parasitic worm. 
It is particularly common along the west coast of Africa, in Senegal and 
Guinea, and in Egypt, Persia, and India. It has also been met with in the 
West Indies. Cases have likewise been reported as occurring in this country, 
but usually in persons who have lived in tropical climates. 

The appearance presented is sometimes that of a cord under the skin, 
often of a dusky red color, sinuous and slightly raised above the general 
level of the skin. At other times, especially when the pregnant worm is 




ANIMAL PARASITES OF MINOR IMPORTANCE. 469 

very much swollen and about to bring forth its ova, the lesion of the skin 
resembles a boil. Sometimes the parasite is single, at other times a great 
number, even hundreds, may exist under the skin, in the intermuscular 
areolar tissue and even in the parenchyma of some of the internal organs. 
The full-grown worm is from 2V to tV inch in thickness, and varies from 
several inches to three feet in length, according to its age. The young worm, 
when of microscopic size, finds its way by boring into the skin and deeper 
tissues, and there takes up its habitat, growing gradually, for months, with- 
out attracting attention, until it attains a 
sufficient size to excite irritation and inflam- 
mation. The disease is usually contracted 
in low swampy places, by persons who go 
barefoot, and usually attacks the feet and 
lower extremities, though the exact mode of 
entrance is unknown. The treatment com- 
monly employed in the countries where the 
disease is endemic consists in extracting the 
worm, inch by inch, and day by day, as soon 

as it makes its appearance on the surface, ^ ,_, .. a , . . 

rr . rio. 101. — I he jigger flea (cm- 

being careful not to break the creature during g0 e). (After Karsten.) 

the operation. Galvanism has also been 

applied with success, one pole of the battery being placed on the head of the 

worm, and the other held by the patient. 

Among medicines iodide of potassium in moderate doses has been em- 
ployed successfully, but the best treatment is that of Horton, by means of 
large doses of asafcetida (foj-ij, (4-8.) twice daily). 

Emily recommends the injection of a 1-1000 solution of bichloride of 
mercury into the little convoluted cord-like swelling produced by the Guinea- 
worm when she begins to approach the skin prior to piercing it; the worm 
is killed and gives no further trouble, being absorbed subsequently like a 
piece of aseptic cat-gut. He uses a hypodermic syringeful of the solution, in- 
jecting it through several punctures. Should the head of the worm be pro- 
truding he pierces the worm itself with the needle and injects the solution into 
her body. Next day she can readily be withdrawn. There is no pain and 
no inflammation and the duration of treatment is three or four days. 

Cysticercus Cellulosce. The cysticercus is found in the skin in about 5 per 
cent, of all affected cases. It is chiefly encountered in North Germany where 
raw or half -cooked pork is a favorite article of diet. The tumor caused by its 
presence is situated under rather than in the skin and varies in size from a 
large pea to that of a walnut, and is firm, round or ovalish in shape. There 
may be several or many. The tumors are usually not painful unless in- 
flamed. The outer skin does not usually show any change. After reaching 



47o 



DISEASES OF THE SKIN. 



a variable size the tumors may become stationary or even retrograde when 
calcification of the contents has taken place. The trunk and to a less de- 
gree the extremities are the usual localities. 

Demodex jolliculorum is a minute, microscopic 'parasite found in the se- 
baceous follicles, chiefly those of the nose. It is entirely without signifi- 
cance in man, although in animals a similar parasite sometimes causes in- 
flammatory reaction. 

(Estrus (gad-fly; bot-fly). The larva of the oestrus, or bot-fly, sometimes 

gives rise to serious symptoms in the 
human being. The ibot-fly of cattle 
lays its eggs in the skin, opened for that 
purpose by its lancet-like ovipositor, 
about August, and when the egg is 
hatched the larva penetrates more 
deeply by means of hooklets attached 
to its head, and disappears entirely, 
being not more than fifteen millimeters 
in length by four in diameter. The 
larva develops slowly and produces 
no irritation for some time; it is about 
nine months before it becomes fully 
developed. 

When fully grown the larva of 
oestrus bovis is twenty-two to twenty- 
eight millimeters in length by eleven 
to fifteen millimeters in breadth. It 
then emerges from the skin. It is 
when about two-thirds grown — that is 
some six months after having been 
deposited in the skin — that the para- 
site begins to be felt, producing a 
furuncle-like lesion growing more and 
more painful, until the insect is finally 
expelled in the spring. The lesions 
usually occur on uncovered parts, as the scalp, neck, face and nucha. Some 
varieties, as the "Macaque," "Dermatobia noxialis," etc., occurring in Cen- 
tral and South America, are more severe in their effects than the oestrus. 
The treatment consists in opening the skin with a lancet and applying pure 
carbolic acid. 

Creeping Larvce. Under the name of " creeping eruption," '' larvae mi- 
grans," etc., a curious and rare disease of the skin has been described 
which is characterized by the appearance of a thin, red, serpiginous line, ele- 




Fio. 102. — Creeping eruption (larva 
migrans). (Courtesy of Stelwagon.) 



ANIMAL PARASITES OF MINOR IMPORTANCE. 47 1 

vated or not, which extends from one or the other extremity sinuously from 
point to point under the skin. Any part of the body may be attacked but 
it is more usual in the extremities. It appears, in some cases, to have oc- 
curred after exposure in the bare feet to sandy seashores. The formation 
is due to a wandering larva which, it is said, may be perceived by pressing 
a piece of glass on the skin and examining it with a lens, when a minute 
black speck is seen. The treatment consists in applying a caustic just be- 
yond the apparent point of progression of the red line which marks the 
progress of the larvae, although in one case under my care the internal ad- 
ministration of large doses of asafcetida seemed to kill the parasite and put 
an end to the progress of the disease. 

Craw-Craw is a disease of the west coast of Africa, somewhat resembling 
scabies. The exact parasite is a subject of dispute. The eruption appears 
usually in the fingers and forearms, consisting of papules, vesicles and pus- 
tules, discrete or crowded, and sometimes with considerable crusting and is 
exceedingly itchy. There are no cuniculi, however, as in scabies. Baths 
and parasiticides constitute the treatment. 

The Echinococcus larva and the distoma hepaticum have both been found 
in the skin. They are described in works on internal medicine and on 
human parasites in general. 



INDEX 



Absorp ion, 22 
Acarus scabiei, 463 
Acanthosis nigricans, 224 
Acne, 400 

diagnosis, 404 
etiology, 402 
pathology, 404 
treatment, 405 
Acne cachecticorum, 403 
Acne hypertrophica, see acne rosacea, 

416 
Acne indurata, 402 
Acne varioliformis, 414 
necrotica, 414 
lupoid, 414 
Acne vulgaris, see acne, 400 
Acne rosacea, 415 

diagnosis, 418 
etiology, 417 
pathology, 417 
treatment, 418 
Acromegaly, 253 
Actinomycosis, 452 
Adenoma sebaceum, 272 
Adenoma of the sweat glands, 273 
Ainhum, 263 
Albinismus, 263 
Alopecia, 376 

idiopathic premature, 376 
senile, 376 
congenital, 376 
symptomatic, 377 
treatment, 377 
Alopecia areata, 380 

diagnosis, 383 
etiology, 383* 
treatment, 384 
Alopecia syphilitica, 387 
treatment, 387 
Anaesthesia of the skin, 351 
Anatomical tubercle, 287 
Anatomical wart, 287 
Anatomy of the skin, 1 



Arrectores pilorum, 10 
Angiokeratoma, 244 
Angioma pigmentosum et atrophicum, 
see xeroderma pigmentosum, 

33° 

Angioma, see naevus vasculosus, 277 
cavernosum, 277, 279 

Angioma serpiginosum, 280 

Anidrosis, 426 

Animal parasites, diseases due to, 455 

Animal parasites of minor import- 
ance attacking the skin, 461 

Animal parasites of minor importance 
penetrating the skin, 467 

Anthrax, see pustula maligna, 185 

Ants, 463 

Argas, 462 

Argyria, 220 

Asteatosis, 396 

Atrophia cutis, 259 

Atrophia maculata et striata, 260 

Atrophia pilorum propria, 369 

Atrophies, 259 

Atrophy, cutaneous, see atrophia cutis, 

259 

unilateral facial, 260 
Atrophy of hair, 369 * 

Bath pruritus, 343 

Bearded woman, see hypertrichosis, 

362 
Bed-bug, 461 
Bees, 463 

Birth mark, see naevus vasculosus, 277 
Blastomycetic dermatitis, 454 
Blebs, 25 

Bloody sweat, see haematidrosis, 429 
Blood, tears of, see haematidrosis, 

43° 
Blood-vessels of the skin, 7 
Boil, Delhi, 319 
Boil, see furuncle, 177 
Bot-fly, 470 



473 



474 



INDEX. 



Bromidrosis, 426 

treatment, 427 
Bullae, see blebs, 25 
Bullous syphiloderm, 
Burmese ring-worm, 



314 

449 



Callositas, 226 
Canities, 374 
Carbun cuius, 181 

diagnosis, 182 

etiology, 182 

pathology, 182 

treatment, 182 
Carbuncle, 181 
Carcinoma cutis, 321 
Caterpillars, 463 
Cauliflower excrescence, see verruca 

acuminata, 232 
Cells, horn, 5 
Cerumen, 21 
Chloasma, 218 

diagnosis, 219 

etiology, 219 

pathology, 219 

treatment, 220 
Chloasma, 218 

idiopathic, 219 

symptomatic, 219 

uterinum, 219 
Chicken-pox, see varicella, 209 
Chigoe, 468 

Chilblain, see dermatitis calorica, 193 
Chromidrosis, 428 

black, 428 

See also seborrhcea nigricans 
Chromidrosis, red, 373 
Cicatrix, 265 
Cimex lectularius, 461 
Classification, 30 
Clavus, 225 

Colloid degeneration of the skin, 277 
Colloid milium, 277 
Comedo, 398 

treatment, 399 
Cornu cutaneum, 235 
Corn, see clavus, 225 

hard, 225 

soft, 225 
Condyloma acuminata, 231 
Corpuscles, tactile, 9 
Corium, 5 
Craw-craw, 471 



Creeping larvae, 470 

eruption, 470 
Crusts, 27 
Culex anxifer, 463 
Culex pipieus, 463 
Cutis pendula, see fibroma, 284 
Cysticercus cellulosae, 469 

Delhi boil, 319 

Demodex folliculorum, 470 

See comedo, 398 
Depilatories, 366 
Dermatitis, blastomycetic, 454 
Dermatitis calorica, 192 
Dermatitis congelationis, 192 
Dermatitis exfoliativa, 61 

diagnosis, 62 

etiology, 62 

pathology, 62 

treatment, 63 
epidemica, 63 
neonatorum, 63 
Dermatitis factitia, 202 
Dermatitis gangrenosa infantum, 189 
Dermatitis herpetiformis, 160 

diagnosis, 163 

etiology, 163 

pathology, 163 

treatment, 163 
Dermatiis medicamentosa, 205 
Dermatitis papillaris capillitii, 268 
Dermatitis repens, 169 
Dermatitis venenata, 195 

diagnosis, 196 

etiology, 195 

treatment, 197 
Dermatitis, X-ray, 200 
Dermanyssus gallinae, 402 
Dermatalgia, 352 
Dermatobia noxialis, 470 
Dermatolysis, 257 

See fibroma, 284 
Diabetic gangrene, 191 
Diseases of the appendages of the 

skin, 353 
Diseases of the nails, 353 
Diseases of the sebaceous glands, 392 
Dissection wounds, 184 
Distoma hepaticum, 471 
Dog-faced man, the Russian, see hy- 
pertrichosis, 364 
Dracunculus, 468 



INDEX. 



475 



Drug eruptions, see dermatitis medic- 
amentosa, 205 

Ecchymoses, 23 
Echinococcus larvae, 471 
Ecthyma, 174 

diagnosis, 175 

etiology, 175 

pathology, 175 

treatment, 176 
Eczema, 83 

erythematosum, 84 

impetiginosum, 85 

papulosum, 87 

pustulosum, 85 

rub rum, 87 

squamosum, 89 

vesiculosum, 85 
Eczema, etiology, 90 

diagnosis, 91 

treatment, 95 
Eczema sycosiforme, 122 

anus, 128 

beard, 123 

breasts, 129 

ears, 124 

eyelids, 121 

face, 117 

genitals, 126 

hands, 133 

in infants, 137 

intertrigo, 129 

leg, 130 

lips, 119 

nares, 121 

of the scalp, 114 
treatment, 115 

palms, 134 

soles, 134 

umbilicus, 130 

universal, 114 
Eczema seborrhceicum, 141 
diagnosis, 142 
etiology, 142 
pathology, 142 
treatment, 143 
Elastic skin man, see dermatolysis, 257 
Elephantiasis, 251 

arabum, 251 

etiology, 253 

pathology, 253 

treatment, 253 



Elephantiasis, telangiectodes, 253 
Ephidrosis cruenta, see haematidrosis, 

429 
Epidermis, 1 

Epidermolysis bullosa, 168 
Epithelioma, 321 
diagnosis, 325 
etiology, 324 
pathology, 325 
treatment, 327 
Epithelioma, multiple benign cystic, 

272 
Epithelioma adenoides cysticum, see 
multiple benign cystic ade- 
noma, 272 
Equinia, 184 
Erysipelas, 186 
diagnosis, 187 
etiology, 187 
pathology, 187 
treatment, 187 
Erysipeloid, 188 
Erythema, 37 

hyperaemicum, 37 
simplex, diagnosis, 37 

treatment, ^8 
infectiosum, 37 
intertrigo, ^8 

diagnosis, 39 
treatment, 39 
Erythema gangrenosum. 189 

See dermatitis gangrenosa infan- 
tum 
Erythema induratum, 48 
diagnosis, 49 
etiology, 49 
treatment, 49 
Erythema nodosum, 47 
diagnosis, 48 
pathology, 47 
treatment, 48 
Erythema scarlatinoides, 40 
scarlatiniforme, 40 
diagnosis, 41 
etiology, 41 
prognosis, 42 
treatment, 42 
Erythema multiforme, 43 
papulatum, 43 
iris, 43 _ 
diagnosis, 45 
etiology, 45 



476 



INDEX. 



Erythema multiforme, pathology, 45 

treatment, 46 
Erythematous syphiloderm, 308 
Erythrasma, 452 
Erythromelalgia, 352 
Excoriations, neurotic, see multiple 
gangrene of the skin in adults, 
189 

Farcy, see equinia, 184 
Favus, 435 

Feigned diseases of the skin, see der- 
matitis factitia, 202 
Fibroma, 281 

diagnosis, 285 

etiology, 284 

pathology, 285 

treatment, 285 
Fibromyomata, see myoma, 286 
Filaria medinensis, 468 
Fissures, 28 
Flea, 461 
Flea, sand, 468 
Flies, 463 
Fly, bot, 470 
Fly, gad, 470 

Folliclis, see acne varioliformis, 414 
Folliculitis decalvans, 388 
Fragilitas crinium, 370 
Frambcesia, 319 
Freckles, see lentigo, 218 
Fungous foot of India, see mycetoma, 

454 
Furun cuius, 177 

diagnosis, 179 

etiology, 178 

pathology, 179 

treatment, 179 
Furuncle, 177 

Gad-fly, 470 

Gangrene, diabetic, 191 

Gangrene, disseminated, see multiple 
gangrene of the skin in adults, 
189 

Gangrene, hysteric, see multiple gan- 
grene of the skin in adults, 189 

Gangrene of the skin, multiple, in 
adults, 189 

Gangrene of the skin, spontaneous, 
see multiple gangrene of the 
skin in adults, 189 



Gangrene, symmetric, 191 
Gangrenous zoster, see multiple gan- 
grene of the skin in adults, 189 
"Gelatine, Pick's," in 

"Jameson's," 112 
Geromorphism cutanee, 260 
Glands, diseases of sweat, 422 
Glands, sebaceous, n 

sweat, 12 

coil, 12 
Glanders, see equinia, 184 
Glossy skin, 260 
" Glycerol e of the r.ubacetate of lead, 

Squire's," 112 
Gnat, 463 
Goose flesh, 9 
Granuloma, fungoides, 331 
Granulosis rubra nasi, 433 
Guinea-worm disease, 468 
Gumma, scrofulous, 290 
Gummatous syphiloderm, 313 

Haematidrosis, 217, 429 
Hemorrhages, 213 
Hair, 14 

follicle, 14 

papilla, 16 

minute structure, 16 

root, 17 
Hair and hair follicles, diseases of, 360 
Hair, atrophy of, 369 

beaded, 371 

moniliform, 371 

ingrowing, 374 

graying of, 374 

falling of, see alopecia, 376 
Hair, loss of, from syphilis, 377 
Harvest mite, see leptus, 467 
Hereditary syphilis, skin diseases in, 

Hemiatrophia facialis, 260 
Herpes, 144 

simplex, 144 

diagnosis, 146 

etiology, 145 

treatment,' 147 
progenitalis, 148 

diagnosis, 149 

treatment, 149 
Herpes zoster, 150 

diagnosis, 157 

etiology, 152 



INDEX. 



477 



Herpes zoster, pathology, 153 

treatment, 157 
Herxheimer's spirals, 3 
Hidradenitis suppurativa, see acne 

varioliformis, 414 
Horn cells, 5 

Horns, see cornu cutaneum, 235 
Hydradenome eruptif, see multiple 

benign cystic adenoma, 272 
Hydroa vacciniforme, 159 
Hydroadenitis suppurativa, 434 
Hydrocystoma, 432 
Hyperemias, 37 
Hyperesthesia of the skin, 352 
Hyperidrosis, 422 

etiology, 423 

treatment, 423 
Hypertrichosis, 360 
Hypertricosis, pathological, 365 

from diseases of nervous system, 

3 6 5> 3 66 
treatment, 366 
Hypertrophies, 218 

Ichthyosis, 238 
diagnosis, 240 
etiology, 240 
pathology, 240 
treatment, 240 
fcetalis, 242 
hystrix, 243 
Ihle's ointment, 112 
Impetigo contagiosa, 171 
diagnosis, 173 
etiology, 173 
pathology, 173 
treatment, 174 
Impetigo herpetiformis, 177 
Impetigo simplex, 169 
diagnosis, 170 
etiology, 170 
treatment, 171 
Inflammations, 43 
Ingrowing hairs, 374 
Itch, grocer's, 
bakers, 

See eczema, 133 
Itch, Malabar, see tinea imbricata, 449 
Itch, the, see scabies, 463 
Hungarian, 465 
Polish, 465 
Italian, 465 



Itch, lumbermen's, see scabies, 465 
Itch, winter, 345 

frost, 345 
Ixodes, 461 

bovis, 461 

Jigger, 468 

flea (fig.), 469 

Keloid, 265 

diagnosis, 267 

etiology, 266 

pathology, 267 

treatment, 267 
Keloid of Addison, see scleroderma 

localis, 247 
Keratohyalin, 4 
Keratin, 5 
Keratosis follicularis, 230 

contagiosa, 231 
Keratosis palmaris et plantaris, 227 
Keratosis pilaris, 229 
Keratosis senilis, 228 
" Kummerfeldt's lotion," 419 
Larvae, creeping, 470 

migrans, 470 
"Lassar's paste," 103 
Layer, basal, 41 

prickle cell, 3 

granular, 3 

papillary, 5 

reticular, 5 
"Lead, glycerole of the subacetate, 

Squire's," 112 
Lentigo, 218 
Lepothrix, 373 
Lepra, 335 

diagnosis, 340 

etiology, 339 

pathology, 340 

treatment, 343 
Leprosy, see lepra, 335 
Leptus, 467 

irritans, 468 

autumnalis, 468 
Lesions, primary, 23 
Leukopathia ungu um, 356 
Lichen tropicus, see miliaria, 433 
Lichen ruber, 65 

acuminatus, 65 
diagnosis, 66 
pathology, 66 



478 



INDEX. 



Lichen ruber, treatment, 66 
Lichen ruber planus, 65, 66 

diagnosis, 67 

etiology, 67 

pathology, 67 

treatment, 68 
Lichen scrofulosus, 69 

diagnosis, 71 

etiology, 71 

pathology, 71 

treatment, 71 
Lichen urticatus, 52 
"Liquor carbonis de'ergens," 118 
"Liquor picis alkalinus," 109 
Lotion, " Kummerfeldt's," 419 
Lotio sulphuris cum tragacanthae, 

418 
Louse, head, 456 
body, 458 
crab, 460 
Louse, chicken, see dermanyssus gal- 

linae, 462 
Lousiness, see pediculosis, 455 
Lupus vulgaris, 292 

diagnosis, 294 

treatment, 295 
Lupus erythematosus, 302 

diagnosis, 304 

etiology, 303 

pathology, 303 

treatment, 304 
Lymphatics, 8 
Lymphangiona, 273 
Lymphangioma tuberosum multiplex, 

274 
Lymphangioma simplex, 273 
cystoides, 273 
cavernosum, 273 
circumscriptum, 273 
Lymph scrotum, 253 

Macaque, 470 
Macrocheilia, 273 
Macroglossia, 273 
Maculae atrophicae, 260 
Macules, 23 

Malabar itch, see tinea imbricata, 449 
Malignant pustule, 185 
Malpighii, stratum, 3 
" Manec's paste," 327 
"McCall Anderson's ointment," 105 
"powder," 102 



Megalosporon, tricophyton, 438 

Microsporon Audouini, 438 

Microsporon furfur, 450 

Miliaria crystallina, see sudamen, 432 

Miliaria, 433 

vesiculosa, 433 
rubra, 433 
papulosa, 433 

Milium, 396 

Milk crust, 85 

"Mistura ferri acida, " 95 

Mite, harvest, see leptus, 467 

Moist papule, 309 

Mole, see naevus pigmentosus, 221 

Molluscum, contagiosum, 270 

Molluscum fibrosum, see fibroma, 281 

Morbus maculosus Werlhofii, see pur- 
pura, 214 

Mother's mark, see naevus vasculosus, 
277 

Monilethrix, 371 

Morphcea, see scleroderma localis, 
247 

Mosquito, 463 

Mucous patch, 309 

Multiple benign cystic epithelioma, 
272 

Multiple gangrene of the skin in 
adults, 189 

Muscles of the skin, 10 

Mycetoma, 454 

Mycosis fungoides, see granuloma fun- 
goides, 331 

Myoma, 286 

Naevus pigmentosus, 221 

linear, 223 

lipomatodes, 223 

pilosus, 222 

spilus, 221 

verrucosus, 223 
Naevus vasculosus. 277 
treatment, 278 
Nails, 18 
Nail bed, 18 

matrix, 19 
Nails, diseases of, 353 

atrophy, 356 

degeneration, 358 

disco 1 oration, 358 

hypertrophy, 353 

parasitic diseases of, 35S 



INDEX. 



479 



Nail plate, malformation of, 357 

separation of, 358 
Nerves of the skin, 9 

motor, 9 
Neuro ic excoriations, see multiple 
gangrene of the skin in adults, 
189 
Neuroma, 285 
Neuroses, 344 
New growths, 265 
Nits, see pediculosis capillitii, 457 

Odors of human body, see bromidro- 

sis, 426 
(Edema angioneuroticum, 57 
diagnosis, 58 
etiology, 58 
pathology, 58 
treatment, 58 
(Edema neonatorum, 251 
(Estrus, 470 

Ointment, "McCall Anderson's," 105 
"Hebra's diachylon," 106 
"Wilkinson's," 109 
"Ihle's," 112 
Onychia, 360 
Onychauxis, 353 
Onychogryphosis, 353 

Pachydermatocele, see fibroma, 284 
Pacinian bodies, 9 
Paget's disease, 329 

pathology, 330 

treatment, 330 
Papillae, 6 

vascular, 6 

sensory, 6 

compound, 6 
Papular syphiloderm, 309 
Papule, moist, 310 
Papules, 24 

Parasitic affections, 435 
Parasites, animal, of minor import- 
ance attacking the skin, 461 
Parasites, animal, of minor importance 

penetrating the skin, 467 
Parasites, diseases due to animal, 455 
Parasites, vegetable, disease due to, 435 
Paronychia, 360 
Paste, "Lassar's, " 103 
Paste, "Manec's," 327 
Patch, mucous, 309 



Pediculus capitis, 456 

corporis, 458 

pubis, 460 
Pediculosis, 455 

capillitii, 456 

vestimentorum, 458 

pubis, 460 
Pelio_is rheumatica, see purpura rheu- 

matica, 214 
Pellagra, 50 

diagnosis, 50 

etiology, 50 

treatment, 51 
Pemphigus, 165 

etiology, 166 

prognosis, 167 

treatment, 167 
Pemphigus foliaceus, 165 

vegetans, 166 

vulgaris, 165 
Perforating ulcer of the foot, 264' 
Perifolliculitis, discoid suppurative, 

see ring-worm, 441 
Petechias, 23 
Phlegmona diffusa, 183 
Phosphoridrosis, 431 
Physiology of the skin, 19 
Pian, see frambcesia, 319 
"Pick's gelatine," in 
Piedra, 372 

Pigmentary syphiloderm, 308 
Pigment of the skin, 10 
Pinta disease, 452 
Pityriasis rosea, 59 

diagnosis, 60 

pathology, 60 

treatment, 60 
Pityriasis rubra pilaris, 65 
Psoriasis, 71 

diagnosis, 76 

etiology, 75 

pathology, 75 

treatment, 78 
Poison vine eruption, see dermatitis 

venenata, 195 
Pompholyx, 159 
Porokeratosis, 244 
Port wine mark, see naevus vasculo- 

sus, 277 
Powder, "McCall Anderson's," 102 
Prickly heat, see miliaria, 433 
Primary lesions, 23 



480 



INDEX. 



Primary lesions of the skin, 23 
Prurigo, 64 

diagnosis, 64 

pathology, 64 

treatment, 65 
Pruritus, 344 

diagnosis, 346 

etiology, 346 

treatment, 346 
Pruritus ani, 345 
Pruritus, bath, 345 
Pruritus hiemalis, 345 
Pruritus scroti, 345 
Pruritus vulvae, 344 
Pulex irritans, 461 
Pulex penetrans, 468 
Purpura, diagnosis, 215 

etiology, 215 

pathology, 215 

treatment, 216 
Purpura, 213 

simplex, 213 

haemorrhagica, 213 

Henoch's, 214 

rheumatica, 214 

scorbutica, 217 
Pustula maligna, 185 

diagnosis, 185 

etiology, 185 

pathology, 185 

treatment, 185 
Pustular syphiloderm, 311 
Pustules, 25 

Rhinoscleroma, 286 

Rhus poisoning, see'dermatitis vene 

nata, 195 
Ringworm of the bearded region, 446 
Ringworm of the general surface, 440 
Ringworm of the scalp, 441 

treatment, 443 
Ring-worm, see tinea tricophytina, 437 

burmese, 449 
Rodent ulcer, 322 
Roseola, 37, 38 

Sand flea, 468 
Sarcoma utis, 331 
Sarcoptes scabiei, 464 
Scabies, 463 

diagnosis, 466 

treatment, 466 



Scales, 28 

Scalled head, 85 

Scarlet rash, 40 

Scars, 29 

Sclerema neonatorum, 249 

etiology, 250 

pathology, 250 

treatment, 250 
Scleroderma, 245 

diagnosis, 248 
etiology, 247 
pathology, 248 
treatment, 249 

localis, 247 
Scrofuloderma, 289 
Scrofuloderm, small pustular, see acne 

varioliformis, 414 
Scrofuloderm, large flat pustular, 291 
Scrofuloderm, small pustular, 290 
Scurvy, see purpura scorbutica, 217 
Sebaceous cyst, see steatoma, 397 
Sebaceous glands, diseases of, 392 
Sebaceous glands, n 
Sebaceous secretion, 21 
Seborrhcea, 392 

diagnosis, 394 

etiology, 394 

oleosa, 393 

nigricans, 393 

sicca, 393 

treatment, 394 
Sebum, 21 

Secondary lesions of the skin, 27 
Skin as a protective organ, 19 

as a sensory organ, 19 

as a respiratory organ, 20 

as a secretory organ, 20 
Skin, blood-vessels of, 7 
Skin cancer, see epithelioma, 321 
Skin diseases in hereditary syphilis, 

Smegma praeputii, see seborrhcea, 

393 
Smegma praeputialis, 21 
Spiders, 463 

Spirals, Herxheimer's, 3 
"Spiritus saponis kalinus," 109 
Spoon nail, 357 
"Squire's glycerole of the subacetate 

of lead," 112 
Steatoma, 397 
Stigmata, see haematidrosis, 450 



INDEX. 



481 



Stratum granulosum, 3 

corneum, 4 

lucidum, 4 

lucidum, 4 

malpighi, 3 
Striae atrophica^, 260 
Subcutaneous connective tissue, 7 
Sudamen, 432 
Sudor sanguinosa, see haematidrosis, 

429 
Sweat, bloody, see haematidrosis, 217 
Sweat, bloody, see haematidrosis, 429 

uric acid, see uridrosis, 431 

phosphorescent, see phosphori- 
drosis, 431 
Sweat glands, 12 
Sweat glands, diseases of, 422 
Sweat secretion, 20 
Sycosis vulgaris, 388 

diagnosis, 390 
etiology, 389 
pathology, 390 
treatment, 390 
Symmetric gangrene, 191 
Symptomatology, 22 
Symptoms, objective, 22 
Syphilis, 307 

Syphilitic affections of the skin, treat- 
ment of, 314 

in children, treatment of, 318 
Syphiloderm, the erythematous or 
macular, 308 

bullous, 314 

gummatous, 313 

papular, 309 

pigmentary, 308 

pustular, 311 

tubercular, 313 

vesicular, 310 
Syphilis, hereditary skin diseases in, 

Tactile corpuscles, 9 

Tattoo marks, 220 

Tears of blood, see haematidrosis, 430 

Telangiectasis, 277, 280 

Tetranychus, see leptus, 467 

Tetter, moist, 85 

Tick, see ixodes, 461 

dove, see argas, 462 
"Tinctura saponis cum pice," 108 
Tinea cruris, 441 

31 



Tinea favosa, see favus, 435 

Tinea nodosa, 373 

Tinea sycosis, see ring-worm of the 

bearded region, 446 
Tinea imbricata, 449 
Tinea tricophytina, 437 
Tinea versicolor, 449 
diagnosis, 451 
treatment, 451 
Tissue, subcutaneous connective, 7 
Tooth rash, 85 
Trichorrhexis nodosa, 372 
Trombidium, see leptus, 467 

Americanum, 468 
Tubercular syphiloderm, 313 
Tubercle, anatomical, 287 
Tubercles, 26 
Tuberculosis cutis, 287 

accidental inoculations, 287 

treatment, 291 

pathology, 301 
Tuberculous ulcers, 289 
Tuberculosis verrucosum, 288 
Tumors, 27 
Tylosis, see callositas, 226 

See keratosis palmaris et plan- 
taris, 227 

Ulcers, 29 

Ulcer, perforating, of foot, 264 

Ulcer, rodent, 322 

Ulcers, tuberculous, 289 

Unilateral facial atrophy, 260 

Uridrosis, 431 

Urticaria, 57 

diagnosis, 53 

etiology, 52 

pathology, 53 

treatment, 53 

bullosa, 52 

haemorrhagica, 52 

papulosa, 51 

tuberosa, 52 
Urticaria pigmentosa, diagnosis, 57 
etiology, 56 
pathology, 57 
treatment, 57 

Vaccinal eruptions, 211 
Varicella, 209 

Varicella gangrenosum, see dermatitis 
gangrenosa infantum, 189 



482 



INDEX. 



Vegetable parasites, diseases due to, 

435 
Venereal wart, 232 
Vernix caseosa, 21 
Verruca, diagnosis, 233 

etiology, 233 

pathology, 233 

treatment, 233 
Verruca, 231 

acuminata, 232 

digitata, 232 

juvenilis, 232 

plana, 232 

sebacea, 232 

vulgaris, 231 
Verruga Peruana, 320 
Vesicles, 24 

Vesicular syphiloderm, 310 
Vibices, 23 
Vitiligo, 262 

Wart, anatomical, 287 
Wart, see verruca, 231 

venereal, 232 
Wasps, 463 



Wheals, 26 

Wen, see steatoma, 397 

Xanthoma, 275 

etiology, 275 

pathology, 275 

treatment, 275 
Xanthoma, 275 

multiplex, 275 

palpebrarum, 275 

planum, 275 

tuberculatum, 275 

tuberosum, 275 
Xanthoma diabeticorum, 276 
etiology, 276 
pathology, 276 
treatment, 277 
Xeroderma pigmentosum, 330 
X-ray dermatitis, 200 
X-ray in the treatment of eczema, 

"3- I 37 
seborrhceicum, 143 

Yaws, see frambcesia, 319 



SEP 28 190/ 



